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VbI.  XK  PSrCHOLOQICAL  REVIEW  PUBLICATIONS      JfJ^I^'J^l^, 

N«.  1  Whole  No.  81 

THE 

Psychological  Monographs 

EDITED    BY 

JAMES  ROWLAND  AN  CELL,  University  of  Chicago 
HOWARD  C.  WARREN,  Princeton  University  (Index) 

JOHN  B.  WATSON,  Johns  Hopkins  University   (Review)   and 
SHEPHERD  I.  FRANZ,  Govt.  Hosp.  for  Insane  (Bulletin) 


ON  THE  FUNCTIONS  OF  THE  CEREBRUM 

I 

Symptomatological  Differences  As- 
sociated with  Similar  Cerebral 
Lesions  in  the  Insane 

By 
SHEPHERD   IVORY   FRANZ 

II 

Variations  in  Distribution  of  the 
Motor  Centers 

By 
SHEPHERD   IVORY   FRANZ 

With  the  Assistance  of 
J.    DUERSON    STOUT 


PSYCHOLOGICAL  REVIEW   COMPANY 

PRINCETON,   N.  J. 
AND   LANCASTER,  PA. 

Agents:    G.  E.  STECHERT  &  CO.,  London  (2  Star  Yard,  Carey  St.,  W.  C); 
Leipzig  (Koenigstr.,  37);  Paris  (16  rue  de  Cond6) 


1 2 1 1  i  4 


ii)U 

335^ 
HIS 

PREFACE 

1 

The  two  articles  which  constitute  the  present  monograph  deal 
with  the  same  gen'eral  topic,  the  variations  in  function  of  cor- 
responding parts  of  different  brains.  This  matter  has  received 
scant  attention  in  neurological  literature,  notwithstanding  the 
fact  that  the  anatomical  variations  have  been  extensively  studied. 
The  data  recorded  in  the  two  articles  point  to  a  conclusion  which 
helps  to  an  understanding  and  to  a  conciliation  of  some  apparent 
discrepancies  in  previous  clinical  and  experimental  studies  of 
cerebral  function.  The  theoretical  discussion  which  is  given  is, 
however,  not  due  soltely  to  the  work  now  presented,  but  in  great 
part  has  been  the  result  of  previous  personal  observations  and  of 
various  facts  which  have  been  recounted  in  clinico — and  physi- 
ological— neurological  literature. 

[^  The  expterimental  data  of  the  second  article  were  collected  be- 
fore the  examination  of  the  clinico-pathological  data  contained 
in  the  first  article  was  begun.  Many  results  of  the  experimental 
study  could  not  be  prepared  for  publication  in  the  present  article, 

1    and  a  number  of  duties  prevented  the  earlier  completion  of  the 

■^^  article  as  it  now  stands,  but  it  is  hoped  that  time  will  be  found 
for  the  early  presentation  of  the  other  collected  facts  which  bear 
upon  the  same  problem.     Part  of  the  first  study  was  prepared  for, 

rbut  was  not  presented  at,  the  conference  on  individual  differences 
at  Columbia  University  in  celebration  of  the  twenty-fifth  anniver- 

1^    sary  of  the  professorship  of  J.  McKeen  Cattell. 

^  In  the  experimental  part  of  the  present  work  the  author  has  had 
the  assistance  of  and  is  under  obligation  to  a  number  of  former 
students,  and  of  internes  at  the  Government  Hospital  for  the 
Insane,  too  numerous  to  mention  separately.  The  major  part  of 
the  assistance  was  given  by  Dr.  J.  Duerson  Stout,  now  associate 
professor  of  physiology  and  pharmacology  in  the  George  Wash- 
ington University  and  his  name  appears,  therefore,  on  the  title 
page. 


PREFACE 

The  research  on  the  brains  of  the  monkeys  was  made  possible 
by  reason  of  a  grant  to  the  author,  for  the  purchase  and  main- 
tenance of  animals  for  the  investigation  of  the  functions  of  the 
cerebrum,  by  the  Carnegie  Institution  of  Washington,  and  for 
making  possible  this  and  other  similar  previous  investigations 
the  author  here  expresses  his  sense  of  obligation. 

For  the  convenience  of  the  reader  it  may  be  mentioned  that 
summaries  of  the  experimental  work  appear  at  the  ends  of  the 
individual  sections  of  that  article  (see  pp.  102,  105,  132,  and  139). 


CONTENTS 

PAGE 

Preface iii 

I.  SYMPTOMATOLOGICAL  DIFFERENCES  ASSO- 

CIATED WITH  SIMILAR  CEREBRAL  LESIONS 

IN  THE  INSANE. 

Introduction i 

Dementia  Precox,  clinical  histories 9 

Dementia  Precox,  discussion 19 

General  Paralysis  of  the  Insane,  clinical  histories 27 

General  Paralysis  of  the  Insane,  discussion 33 

Arteriosclerotic  Dementia,  clinical  histories 39 

Arteriosclerotic  Dementia,  discussion 45 

Senile  Dementia,  clinical  histories 52 

Senile  Dementia,  discussion 65 

Summary 74 

General  Discussion yj 

II.  VARIATIONS    IN    DISTRIBUTION    OF    THE 

MOTOR  CENTERS. 

Introduction 80 

Methods 82 

Experimental  Results 92 

I.  Extents  of  cerebral  motor  areas  for  the  arm  and  leg 

segments 95 

II.  Relative  distributions  of  areas  for  arm  and  leg  move- 
ments      103 

III.  Distributions  of  areas  for  individual  segments 106 

(Thigh,  Leg,  Foot,  Toes,  Shoulder,  Forearm,  Hand, 

Fingers,  General.) 

IV.  Anomalous  distributions  of  the  stimulable  areas. ...    134 
(Arm  movements  within  leg  areas;  Leg  movements 

within  arm  areas ;  Relatively  non-stimulable  zones. ) 

General  Discussion  (Theoretical) 140 

References 162 


SYMPTOMATOLOGICAL  DIFFERENCES 

ASSOCIATED     WITH     SIMILAR 

CEREBRAL  LESIONS  IN 

THE  INSANE 

INTRODUCTION 

It  is  well  known  that  in  different  diseases  similar  symptoms  are 
often  exhibited.  For  example,  anemia  and  fever  are  not  more 
characteristic  of  one  special  disease  than  of  a  multitude  of  others. 
On  the  other  hand,  discomfort  and  malaise  are  so  constantly  re- 
ported by  those  who  are  sick,  that  they  can  not  be  said  to  be  of 
more  than  minor  diagnostic  value.  Even  pains  are  so  commonly 
concomitants  of  different  diseases  that,  except  when  definitely 
localized,  and  not  always  then,  they  almost  cease  to  be  of  diagnos- 
tic or  prognostic  importance.  In  the  mental  disease,  the  individual 
symptom  is  often  less  valuable,  if  this  be  possible,  as  an  indication 
of  the  special  disease.  A  depression  or  a  sadness,  an  hallucination 
or  a  delusion,  defects  of  retention  or  of  comprehension,  and  evi- 
dences of  loose  thinking  and  the  like  are  elements  or  symptoms  in 
many  of  the  psychoses.  Not  one  is  pathognomonic  of  a  special 
disease,  each  is  an  expression  of  a  physiological  conflict  or  of  a 
loss  or  defect  of  anatomical,  and  also  functional,  cerebral  elements. 

Although  no  one  symptom  or  condition  can  be  relied  upon  for 
the  purpose  of  diagnosis,  the  combination  of  symptoms  does  give 
most  often  plain  evidence  of  the  nature  of  the  special  disorder. 
The  recognition  of  the  fact  that  diagnostic  reliance  may  be  placed 
upon  the  collection  or  concatenation  of  symptoms  has  led  to  the 
foundation  and  the  elaboration  of  a  system  of  knowledge,  we 
might  almost  say  a  science,  which  is  called  differential  diagnostics. 
The  development  of  this  field  has  also  been  due  to  the  realization 
that  in  the  same  disease  in  different  individuals  the  micro-or- 
ganisms may  produce  different  effects,  or  the  body  physiologically 


a  SHEPHERD  IVORY  FRANZ 

may  be  affected  differently,  and  there  may  result  different  prom- 
inent systems  in  different  individuals.  Apart  from  the  so-called 
mildness  or  the  severity  of  the  disease,  one  individual  may  ex- 
hibit high  temperature,  another  may  exhibit  a  temperature  only 
slightly  above  the  normal.  In  one  individual  the  diseased  con- 
dition of  one  of  the  heart  valves  may  exist  for  many  years  with- 
out obvious  symptoms  which  attract  the  patient's  attention  because 
of  compensation  in  both  the  strength  and  the  size  of  the  heart, 
while  a  similar  pathological  state  in  another  patient  gives  rise 
to  distress,  sharp  pains  and  faintness. 

These  similarities  of  symptoms  in  different  diseases  and  the 
variations  in  symptoms  in  different  individuals  with  the  same 
disease  are  paralleled  by  variations  in  actions  of  different  drugs 
and  by  differences  in  the  reactions  of  different  individuals  to 
some  foods.  In  some,  the  eating  of  strawberries  or  of  fish  is 
accompanied  by  disagreeable  effects,  and  in  other  individuals 
the  effects  following  the  administration  of  therapeutic  doses  of 
certain  drugs  are  not  only  disagreeable  but  often  dangerous. 
Small  amounts  of  the  derivatives  of  opium,  of  arsenic,  of  antipy- 
rine,  and  of  even  generally  supposed-to-be-harmless  quinine  at 
times  give  rise  to  violent  physiological  reaction,  although  most 
people  may  take  small  doses  of  these  drugs  with  impunity  and 
without  apparent  physiological  changes. 

In  the  older  psychiatry  individual  symptoms  or  concomitant 
physical  conditions  were  uncritically  believed  to  have  major 
importance  and,  because  of  this,  dissimilar  diseases  were  consider- 
ed to  be  the  same.  When  certain  etiological  factors  were  deter- 
mined and  when  the  symptomatological  variations  were  carefully 
considered  it  became  apparent  that  superficially  different  group- 
ings of  symptoms  might  be  and  often  are  essentially  similar. 
Notwithstanding  these  supposedly  fundamental  similarities  as 
we  see  them  at  present,  there  remain  many  prominent  points  of 
differences  in  the  symptoms  in  individuals  who  suffer  from  the 
same  disease.  These  individual  differences  have  been  supposed 
to  be  due  to  or  to  be  connected  with  variations  in  the  normal 
mental  make-up  of  the  patient,  or  to  variations  in  lesions  or  in 
functional  disturbances  of  cerebral  centers  or  connections. 


SYMPTOM ATOLOGICAL  DIFFERENCES  IN  THE  INSANE        3 

To  account  for  the  individual  variations  in  both  mental  and 
nervous  diseases,  the  psychoses  and  the  neuroses,  it  has  been 
most  easy  and  quite  satisfying  to  presuppose  functional  and 
structional  differences  of  the  lesions,  because  of  our  relative 
ignorance  of  many  of  the  functions  and  of  the  anatomical  con- 
nections of  parts  of  the  nervous  system.  This  is  specially  true 
when  we.  deal  with  lesions  or  disease  of  the  cerebrum  and  the 
basal  ganglia.  Within  recent  years,  however,  there  has  been 
growing  the  realization  that  a  minute  lesion  in  one  part  of  the 
brain  may  give  rise  to  a  symptom  or  to  a  collection  of  symptoms 
which  is  exactly  the  same  as  that  resulting  from  a  similarly 
minute  lesion  in  a  second  or  a  third  portion  of  that  organ.  If 
we  liken  the  cerebral  mechanism  to  the  stations  and  lines  of  a 
telephone  or  a  telegraph  plant  we  may  readily  understand  how 
this  can  be.  If  the  emissive  element  or  the  transmitter  be  broken 
or  destroyed  it  is  not  possible  to  transmit  the  message  in  a  par- 
ticular direction  or  to  a  given  point.  The  function  is  abolished. 
But  we  must  also  keep  in  mind  that  a  similar  abnormal  condition 
of  function  arises  if,  instead  of  having  a  lesion  of  the  emissive 
element,  there  be  a  break  in  any  part  of  the  conducting  line. 
Such  an  injury  or  a  disease  may  be  close  to  or  far  from  the 
transmitter  and  may  even  be  in  the  receiver. 

Lesions  in  the  nervous  system  minute  enough  to  embrace  an 
individual  nerve  cell  or  its  processes  are  never  found.  The 
smallest  always  involve  many  elements.  But  even  though  this 
be  true,  it  has  been  shown  that  such  lesions  in  different  parts  may 
result  in  similar  physiological  disturbances.  Lesions  of  such 
widely  separated  parts  of  the  nervous  system  as  the  frontal 
lobes  and  the  cerebellum  are  known  to  produce  similar  symp- 
toms, and  in  many  cases  a  definite  diagnosis  can  be  made  only 
after  death.  Usually,  however,  concurrent  with  the  main,  or 
with  the  more  prominent,  symptoms  other  symptoms  are  found. 
These  additional  symptoms  point  to  disturbances  of  structures 
anatomically  alHed  to  the  one  which  is  chiefly  involved  or  which 
is  entirely  destroyed,  and  they  permit  fairly  accurate  neurological 
diagnostic  localizations  in  many  cases  during  life.     Thus,   for 


4  SHEPHERD  IVORY  FRANZ 

example,  we  find  it  possible  to  predict  the  localizations  of  lesions 
in  individuals  with  paralyses  because  of  the  association  of  several 
paralyzed  segments,  or  because  of  concomitant  sensibility  dis- 
orders. 

The  reverse  state  of  affairs  is  seldom  considered.  Is  it,  we  may 
ask,  possible  that  anatomically  similar  lesions  of  the  cerebrum 
give  rise  to  dissimilar  symptoms  in  different  individuals?  The 
consequences  of  a  positive  or  a  negative  answer  to  this  question 
are  of  great  importance.  If  similar  cerebral  lesions  do  not  al- 
ways produce  similar  symptoms,  there  is  opened  a  series  of 
problems  regarding  the  "why"  and  the  "how"  of  cerebral  func- 
tion which  are  fundamental.  If  similar  cerebral  lesions  are 
always  accompanied  by  similar  mental  changes,  our  conceptions 
of  cerebral  mechanics  may  remain  simple  and  our  explanations 
of  the  relations  of  mental  and  cerebral  functions  become  less 
difficult. 

Because  of  these  considerations  it  appeared  desirable  to  make 
a  special  study  of  possible  differences  in  symptoms  accompanying 
similar  cerebral  lesions.  For  this  purpose  there  were  available 
autopsy  and  clinical  records  of  nearly  3,300  patients  who  had 
been  in  the  Government  Hospital  for  the  Insane.  The  clinical 
records  of  many  were  so  meagre  that  attempted  correlations  of 
the  cerebral  lesions  with  the  clinical  symptoms  would,  in  these 
cases,  have  been  futile,  and  it  appeared  would  have  resulted  in 
a  loss  of  time.  For  this  reason  only  those  cases  have  been 
considered  in  which  there  were  recorded  the  results  of  fairly 
complete  mental  examinations  as  well  as  the  autopsy  examina- 
tions. These  considerations  resulted  in  the  primary  rejections 
of  all  but  the  last  950  autopsy  cases,  representing  roughly  those 
autopsies  which  had  been  performed  during  the  past  six  or  seven 
years.  It  was  also  found  that  about  one-third  of  these  must 
also  be  rejected  on  account  of  insufficient  clinical  examinations, 
and  because  of  indefinite  diagnostic  data.  The  cases  which  were 
eventually  selected  were  of  all  kinds  of  mental  diseases,  but  the 
series  is  particularly  strong  in  the  organic  psychoses,  such  as 
paresis,  arteriosclerotic  dementia,  senile  dementia,  and  the  like. 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE       5 

The  brains  of  these  individuals  showed  a  great  variety  of 
lesions,  inflammatory,  atrophic,  hemorrhagic,  and  the  like.  These 
were  divided  into  two  general  groups,  one  in  which  there  was  a 
single  or  unitary  lesion,  the  other  in  which  there  was  a  com- 
bination of  cerebral  lesions.  Those  in  which  there  were  two 
kinds  of  lesions,  e.  g.,  softening  and  atrophy,  were  excluded. 
The  cases  which  showed  atrophy  were  the  most  numerous  and 
these  were  selected  for  the  present  study.  These  were  separated 
into  two  general  classes:  (i)  Those  in  which  the  atrophy  was 
general  but  in  which  there  might  be  a  greater  atrophic  condition 
in  one  portion  of  the  cerebrum, and  (2)  those  in  which  the  atrophy 
was  well  localized  in  one  special  region  of  the  cerebral  cortex. 
The  second  group  is  the  one  which  has  been  more  carefully  stud- 
ied at  the  present  time.  From  this  group,  as  has  been  stated 
above,  there  have  been  omitted  almost  all  those  cases  in  which 
there  were  other  gross  lesions  of  parts  of  the  cerebrum  or  of  the 
nervous  system  in  general.  A  few  cases  in  which  the  only  ad- 
ditional lesions  were  recent  cerebral  hemorrhages,  that  resulted 
in  the  death  of  the  patients,  were  included,  because  whatever 
mental  changes  had  been  observed  during  the  major  part  of 
their  hospital  residence  could  not  have  been  due  to  these  lesions. 
It  might  also  have  been  possible  to  include  certain  cases  in  which 
localized  softenings  accompanied  the  atrophy,  because  in  a  num- 
ber of  cases  these  additional  pathological  conditions  were  due  to 
comparatively  recent  cerebral  insults.  Since,  however,  definite 
dates  could  not  be  assigned  to  some  of  them,  they  have  been 
excluded  from  the  present  report. 

The  atrophies  which  are  dealt  with  here  are  those  which,  as 
defined  by  Blackburn^,  imply  "reduction  in  size  and  weight  of 
an  organ  which  has  been  at  one  time  of  greater  volume  and  weight, 
though  the  organ  may  not  have  been  orginally  up  to  the  normal 
standard.  It  also  implies  that  this  atrophy  is  the  result  of  de- 
generation and  diminution  of  the  elements  of  the  tissue  and  not 
merely  the  result  of  pressure  or  gross  loss  of  substance."  In 
old  age  this  condition  of  atrophy  of  the  cerebrum  is  met  with  as 

*  Blackburn,  I.  W.    Atrophy  of  the  Brain  in  the  Insane.     Govt.  Hasp,  for 
the  Insane  Bull.,  191 1,  3,  45-50. 


6  SHEPHERD  IVORY  FRANZ 

a  common  concomitant  of  the  general  bodily  degenerative 
changes,  and  it  may  be  due  solely  to  these  degenerative  tend- 
encies of  the  body  as  a  whole.  The  condition  of  cerebral  atrophy 
is  also  to  be  found  in  a  variety  of  other  mental  diseases  besides 
that  of  senile  dementia,  and  it  is  particularly  noticeable  in  many 
cases  of  general  paralysis  of  the  insane.  The  atrophies  may,  it 
has  been  shown,  be  primary,  i.e.,  due  to  degenerations  of  the 
cells,  without  concomitant  changes  in  the  blood  vessels,  or  they 
may  be  the  result  of  partial  blocking  of  or  difficulties  in  the 
course  of  the  blood  flow.  The  atrophies  which  accompany  cerebral 
arteriosclerosis  are  allied,  some  think,  to  the  atrophies  which  are 
found  in  general  paralysis  of  the  insane,  in  that  they  are  atrophies 
of  a  secondary  nature,  whereas  the  atrophies  which  are  found  in 
senile  dementia,  and  possibly  also  in  dementia  precox,  are  more 
.frequently  primary  atrophies.  In  many  cases  the  atrophies  are  so 
distributed  that  it  is  apparent  they  do  not  depend  upon  changes 
in  the  arterial  supply.  In  fact,  in  many  instances  the  gross  and 
also  the  histological  examinations  may  fail  to  show  any  sclerotic 
changes  in  the  blood  vessels.  In  this  connection,  it  may  be  noted 
that  Blackburn  has  pointed  out  that  in  certain  cases  there  may 
be  a  complete  preservation  of  certain  cortical  areas  with  an 
atrophy  of  surrounding  or  neighboring  zones  which  are  sup- 
plied by  the  same  vessel. 

In  many  cases  the  cerebral  atrophy  is  general,  but  regional  atro- 
phies are  frequently  met  with,  such  as  those  of  the  frontal,  or 
parietal  or  temporal  lobes.  In  paresis  it  is  not  uncommon  to 
find  such  localized  atrophies,  and  these  are  more  frequent  in 
the  frontal  lobes.  There  is,  however,  an  atrophy  of  the  parietal 
region,  circumscribed  in  character,  which  has  been  described  by 
Lissauer.  Although  the  symptoms  due  to  this  circumscribed 
atrophic  condition  of  the  posterior  half  of  the  brain  include  cer- 
tain focal  manifestations,  especially  those  of  disturbances  in 
speech  of  the  nature  of  the  aphasias,  the  other  symptoms  do 
not  differ  very  markedly  from  the  symptoms  accompanying  more 
generalized  or  frontal  atrophy,  and  previous  to  death  it  is  not 
usually  possible  to  diganose  this  condition.     Kraepelin^  reports 

*  Kraepelin,  E.,  General  Paresis  (trans,  by  I.  W.  Moore).  Nerv.  and 
Ment.  Dis.  Monog.  No.  14.     Pp.  v  +  200.     (See  especially  pp.  134-135.) 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE       7 

that  in  this  Lissauer  type  of  paresis  the  course  of  the  disease  is 
spasmodic  and  resembles,  to  some  extent,  cortical  epilepsy,  while 
the  deterioration  is  more  gradual  than  in  the  frontal  atrophies. 
This  type  of  case  is  estimated  by  Alzheimer  to  comprise  about 
15  per  cent  of  the  total  cases  of  paresis.  Similar  circumscribed, 
or  regional,  atrophies  are  also  found  in  cases  of  senile  dementia, 
arteriosclerotic  dementia,  and  dementia  precox. 

In  regard  to  the  relation  of  atrophies  to  the  clinical  symptoms 
Blackburn  has  written :  "The  conclusions  reached  by  long  ex- 
perience are  that  in  all  cases  of  insanity  of  long  standing  in  which 
there  is  a  demonstrable  mental  deterioration  we  may  confidently 
predict  that  some  shrinkage  of  the  brain  may  be  found;  that  as 
a  rule  the  degree  of  dementia  is  commensurate  with  the  atrophy 
found  or  present;  and  that  the  localization  of  this  shrinkage  in 
the  prefrontal  region  in  most  cases  is  a  strong  presumptive  evi- 
dence of  the  seat  of  intellectual  processes  in  that  part  of  the 
brain."^  He  furthermore  states  that  the  fact  that  the  secondary 
degenerative  atrophy  "is  confined  most  frequently  to  the  frontal 
lobes  and  the  prefrontal  region  is  strikingly  significant  in  view 
of  the  supposed  intellectual  function  of  these  parts."  On  the 
other  hand,  it  should  be  mentioned  that  senile  dementia  may 
be  evident  without  concomitant  atrophic  conditions  in  the  brain. 
This  is  also  true  for  dementia  precox,  and  whatever  relations 
the  atrophic  conditions  bear  to  the  changes  in  mental  characters 
which  are  grouped  together  under  the  general  term  "mental 
deterioration"  are  at  present  unknown.  Since  deterioration 
may  exist  without  obvious  atrophy  it  is  apparent  that  the 
atrophy,  in  itself,  is  not  necessary  for  the  production  of  the 
symptoms.  That,  however,  the  symptoms  do,  in  many  cases 
at  least,  depend  upon  the  cerebral  changes  we  may  believe.  The 
relation,  direct  or  indirect,  of  the  cerebral  lesions  with  the 
symptoms  has  not  yet  been  sufficiently  shown. 

After  the  elimination   of   the  cases  with  multiple  lesions   a 

total  of  sixty  cases  was  obtained  with  sufficiently  complete  clinical 

and  pathological  histories  to  make  certain  comparisons  of  value. 

Some  of  these  were  not  usable  in  the  present  study  on  account 

•  Op.  cit. 


8  SHEPHERD  IVORY  FRANZ 

of  the  fact  that  they  were  diagnostically  doubtful  cases  or 
there  were  too  few  cases  of  the  special  kind  of  mental  disease 
to  make  valuable  symptom-lesion  correlations.  In  general  it 
was  believed  that  at  least  four  or  more  cases  of  a  particular 
psychosis  were  needed  if  the  individual  differences  and  similari- 
ties were  to  be  dealt  with  properly,  and  on  account  of  this 
twenty-two  cases  were  omitted  from  the  present  work.  The 
omitted  cases  were :  manic-depressive  and  allied  psychoses,  7 ;  in- 
toxication psychoses,  2 ;  imbecility,  i ;  epilepsy  with  dementia,  i ; 
paralysis  agitans,  i ;  cerebral  syphilis,  3 ;  organic  diseases  of  the 
brain  not  otherwise  differentiated,  3 ;  undiagnosed  or  unclassified 
psychoses,  4.  The  remaining  thirty-eight  cases  were  distributed 
as  follows:  dementia  precox,  9;  general  paralysis  of  the  insane, 
6;  arteriosclerotic  dementia,  9;  senile  dementia,  14.  Thirteen 
of  these  cases  were  described  in  the  autopsy  records  as  simple 
frontal  atrophies ;  two  were  cases  in  which  the  brain  was  generally 
atrophied  but  the  atrophies  of  the  frontal  regions  were  great; 
eighteen  cases  were  described  as  anterior  atrophies,  and  by  this  is 
meant  that  the  regions  anterior  to  the  central  fissure  (including, 
therefore,  the  so-called  motor  region  in  addition  to  the  frontal 
area)  were  atrophied;  four  cases  showed  atrophy  over  the  anter- 
ior two-thirds  of  the  cerebrum,  including  therefore  more  of  the 
cortex  than  in  the  cases  previously  mentioned;  one  additional 
case,  in  which  the  atrophy  covered  the  frontal  region  and  the 
posterior  portion  of  the  parietal  area,  was  included  'for  com- 
parison. The  distribution  of  these  extents  of  atrophies  in 
the  different  diseases'  is  given  in  the  accompanying  table  and 
comparisons  are  also  made  in  the  discussions. 


. 

Characters  of  atrophy 

Mental  Diseases 

Frontal 

Frontal 

and 
general 

Anterior 

5 

3 
5 
5 

Anterior 
*wo-thirds 

Frontal 
and  pos- 
terior 
parietal 

Totals 

Dementia  precox  .... 
General  paralysis  of  the 

insane  

Arteriosclerotic  dementia 
Senile  dementia    .... 

3 

3 
2 

5 

0 
0 

2 
0 

I 
0 

0 

3 

0 

0 
0 

I 

I 

9 

6 

9 

14 

Totals 

»3 

2 

18 

4 

38 

DEMENTIA  PRECOX,  CLINICAL  HISTORIES 

Case  I,  white  female,  was  admitted  to  the  Hospital  at  the 
age  of  54  and  lived  for  3  years  and  6  months. 

Her  family  history  was  bad;  her  father  was  nervous,  her 
maternal  cousin  was  insane,  and  her  mother  was  an  invalid  for  a 
number  of  years  before  her  death,  which  was  due  to  ovarian  tu- 
mor; the  patient  attended  private  schools  until  the  age  of  seven- 
teen ;  she  was  considered  to  be  sickly  all  her  life ;  for  many  years 
she  showed  marked  peculiarities  of  conduct,  was  contrary,  and  had 
spells  of  high  temper  at  intervals  varying  from  a  week  to  several 
months;  at  one  time  she  lived  in  an  eighteen-room  house  with 
only  a  dog  for  company  for  a  period  of  fifteen  years.  The  mental 
disorder  which  led  to  her  commitment  was  probably  of  very  long 
standing,  but  the  occasion  of  commitment  was  the  manifesta- 
tion of  delusions  of  persecution  by  "witches"  and  by  the  "Black 
Hand  Society" ;  she  was  also  extremely  nervous,  had  insomia, 
refused  to  eat,  and  exhibited  homicidal  tendencies.  She  would 
not  permit  either  physical  or  neurological  examination,  but  ex- 
hibited no  obvious  physical  or  neurological  abnormalities  except 
a  few  small  sores  over  trunk  and  limbs.  She  was  restless,  suspi- 
cious of  almost  every  one  about  her;  she  refused  to  talk  freely 
about  herself ;  at  times  she  imagined  the  food  was  poisoned  and 
refused  to  take  it  on  this  account,  but  on  being  assured  that 
there  was  no  poison  or  after  it  had  been  tasted  by  another,  she 
would  take  it;  she  also  feared  that  the  towels,  the  combs,  the 
water,  etc.,  contained  poison;  she  had  hallucinations  of  hearing 
(she  had  heard  her  mother's  and  brother's  voices  talking  to  her) 
and  also  of  skin  sensations  (she  said  that  she  was  electrical  and 
could  give  out  power  at  any  time ;  she  also  reported  that  electric 
currents  had  been  turned  upon  her  for  years  by  her  enemies)  ;  she 
believed  that  she  was  especially  favored  by  the  Lord  and  that  she 
received  signs  of  this;  her  memory  was  excellent  and  when  she 
was  persuaded  to  talk,  she  gave  detailed  accounts  of  her  past  and 
of  the  conditions  which  led  up  to  the  persecutions  to  which  she  be- 
lieved she  had  been  subjected ;  her  attention  did  not  appear  to  be 


10  '  SHEPHERD  IVORY  FRANZ 

impaired,  and  there  was  no  distractability ;  she  had  no  apprecia- 
tion of  her  mental  condition ;  she  was  well  oriented  in  all  spheres ; 
there  was  no  clouding  of  consciousness;  she  reported  (in- 
correctly) that  she  did  not  sleep  well;  and  she  answered  in- 
coherently at  most  times.  Later  she  became  indifferent,  but  at 
times  was  noted  to  be  emotionally  labile;  she  was  irresponsible; 
her  answers  were  circumstantial,  irrelevant,  or  incoherent;  at 
times  she  was  disturbed,  noisy,  destructive,  violent,  and  untidy; 
she  wandered  away ;  talked  constantly ;  her  answers  showed  that 
her  memory  was  poor  for  recent  events,  and  there  was  evidence 
of  gradual  mental  deterioration. 

Death  was  due  to  purulent  parotitis  and  bronchopneumonia. 
Besides  these,  the  autopsy  revealed :  diffuse  nephritis ;  pulmonary 
tubercular  nodules;  an  insufficiency  of  the  tricuspid  valve  of  the 
heart ;  numerous  uterine  fibroids  and  endometritis ;  the  brain  was 
slightly  shrunken  in  the  frontal  regions,  but  no  other  gross  cere- 
bral lesions  were  found.  The  histological  examination  showed  a 
slight  chromatolysis  of  the  ganglion  cells,  neuronophagia,  and  an 
increase  of  the  neuroglia. 

Case  2,  white  male,  36  years  of  age  at  the  time  of  admission, 
lived  25  years  and  a  half  in  the  Hospital.  The  duration  of  the 
mental  disease  at  the  time  of  admission  was  noted  as  2  years 
and  3  months. 

His  family  history  was  negative;  the  patient  came  to  the 
United  States  when  young,  entered  the  army,  and,  as  has  been 
indicated  above,  exhibited  for  more  than  two  years  previous  to 
his  entrance  to  the  Hospital  mental  abnormalities.  Physically 
and  neurologically  no  pathological  conditions  were  detected. 
He  was  quiet,  tidy,  had  little  to  say  voluntarily,  but  would  answer 
questions;  his  answers  showed  that  he  had  delusions  of  a  fan- 
tastic nature  which  were  fleeting  in  character,  but  which  did  not, 
however,  appear  to  cause  him  any  discomfort ;  he  appeared  to  be 
indifferent  to  his  surroundings,  but  in  general  was  satisfied  and 
happy,  industrious,  and  he  willingly  helped  with  the  ward  work ; 
his  memory  was  fair;  in  general  he  was  disoriented;  his  delu- 
sions concerned  God  and  religion,  and  combined  with  these,  there 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      ii 

were  auditory  hallucinations  that  the  "Almighty"  talked  with 
him  and  that  other  voices  abused  him,  and  for  that  reason  he 
swore  at  them  occasionally;  he  often  talked  to  himself.  Later 
he  became  almost  completely  disoriented;  memory  became  very 
poor,  for  the  most  part  he  talked  unintelligibly,  but  he  gave 
plain  evidence  of  the  existence  of  delusions;  he  said  that  God 
Almightly  persecuted  him  by  ordering  him  to  do  things  he  did  not 
like  to  do;  he  occasionally  stopped  eating  in  the  midst  of  a  meal 
and  explained  this  as  being  due  to  the  fact  that  God  had  told 
him  to  eat  no  more ;  he  used  very  profane  language  and  swore  at 
times,  and  would  have  nothing  to  do  with  the  other  patients;  he 
asked  for  whiskey  to  drink  so  that  in  this  way  he  might  punish 
God  Almighty;  he  kissed  the  walls;  he  muttered  unintelligibly, 
and  he  informed  a  physician  ■  that  God's  voice  was  inside  his 
body,  and  that  God  talked  so  quickly  that  he  could  not  repeat 
what  was  said ;  he  showed  no  interest  in  his  surroundings  except 
as  exhibited  in  his  daily,  almost  continuous,  polishing  of  the 
floor,  which  he  said  was  done  at  the  command  of  God;  he  had 
practically  no  knowledge  of  current  events;  his  reasoning  and 
judgment  were  very  much  impaired;  he  was  illogical;  his  con- 
duct was  silly ;  and  his  insight  was  almost  lacking. 

At  the  autopsy  there  were  found:  marked  generalized  ar- 
teriosclerosis; calcification  of  the  mitral  valves  of  the  heart; 
hypostatic  congestion  of  the  lungs;  interstitial  nephritis;  and 
shrinkage  of  the  frontal  portions  of  the  cerebrum. 

Case  3,  colored  male,  exhibited  mental  abnormalities  for  5 
or  more  years  previous  to  his  admission  at  the  age  of  30,  Hos- 
pital residence  was  1 1  years  and  6  months. 

Nothing  was  learned  of  this  patient's  family  or  previous  per- 
sonal history  except  that  it  was  reported  he  had  been  mentally 
abnormal  for  at  least  five  years  previous  to  his  admission,  although 
his  marked  mental  abnormality  was  evident  for  only  a  year 
previous  to  his  commitment ;  during  that  time  he  was  noted  to  be 
melancholy  and  restless;  he  showed  extreme  anxiety  and  had 
hallucinations;  he  upset  everything  in  his  room,  and  was  untidy 
and  filthy  in  habits.     Physical  and  neurological  examinations 


12  SHEPHERD  IVORY  FRANZ 

were  negative  except  that  hearing  and  smell  were  slightly  im- 
paired; his  gait  was  slow  and  his  attitude,  although  fairly  erect 
and  steady,  was  slightly  relaxed;  his  actions  in  general  were 
slow,  imperfect,  uncertain  and  unreliable.  He  was  quiet,  dull, 
often  stupid;  he  was  also  untidy;  memory  was  markedly  im- 
paired; his  ideation  was  slow  and  uncertain;  in  general  he  ans- 
wered fairly  well,  although  at  times  irrelevantly;  his  reasoning 
and  judgment  were  bad;  he  appeared  to  have  very  little  mental 
capacity ;  no  hallucinations  or  delusions  were  observed  and  could 
not  be  detected  from  his  actions ;  he  was  unappreciative  and  had 
no  apparent  interest  in  his  surroundings ;  he  appeared  stupid ;  he 
usually  sat  in  one  place  and  assumed  one  position;  he  spoke  only 
when  spoken  to,  and  then  only  after  much  persuasion;  at  times 
he  was  noisy,  turbulent,  talked  incoherently,  and  was  destructive ; 
echopraxia,  mutism,  negativism  and  catatonia  were  observed,  but 
none  of  these  conditions  was  marked ;  orientation  was  lacking. 

The  patient  died  of  tubercular  pneumonia,  and  shrinkage  of 
the  frontal  lobes  of  the  cerebrum  was  also  found  at  the  autopsy. 

Case  4,  white  male,  entered  the  Hospital  at  the  age  of  54  and 
lived  for  18  years. 

He  fought  in  the  Civil  War  and  since  its  ending  (he  was  twenty- 
two  years  old  at  that  time)  was  abnormal,  with  intervening  lucid 
intervals;  the  character  of  his  abnormality  during  this  period  of 
twenty-one  years  was  not  very  clear,  but  presumably  it  was  of  a 
precox  nature.  On  his  entrance  to  the  Hospital  he  was  untidy ;  he 
answered  irrelevantly;  he  exhibited  poor  memory;  he  said  little; 
he  went  out  walking  daily ;  at  times  he  would  not  keep  his  cloth- 
ing on  and  was  filthy  in  habits.  Later  the  patient  was  found  to 
have  interstitial  nephritis,  and  for  about  seven  years  before  his 
death  he  was  almost  entirely  confined  to  bed  on  account  of  this 
pathological  condition  and  heart  disease;  he  became  much  de- 
mented, took  no  interest  in  his  surroundings ;  questions  often  re- 
mained unanswered,  but  if  answers  were  obtained,  they  showed 
no  grasp  of  his  surroundings  and  were  given  in  a  slow,  hesitating 
manner  and  in  so  low  a  voice  as  to  be  almost  inaudible  and  unin- 
telligible; he  talked  to  himself  a  great  deal  and  appeared  to  have 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      13 

auditory  hallucinations;  occasionally  he  arose  from  his  bed  and 
peered  about  the  ward;  echolalia  was  present;  he  remained  most 
of  the  time  in  bed  motionless  with  his  arms  across  his  chest  and 
his  fingers  intertwined. 

Death  was  due  to  purpura  hemorrhagica.  The  autopsy  showed : 
some  heart  disease ;  atheromatous  aorta ;  small  cysts  in  the  kidney ; 
hypernephroma ;  chronic  cytitis ;  the  section  of  the  brain  revealed 
no  lesions  except  atrophy  of  the  anterior  convolutions. 

Case  5,  colored  male,  lived  for  about  2  years  after  admission 
at  the  age  of  23. 

A  brother  and  sister  had  spasms  in  early  life;  otherwise  the 
family  history  was  negative ;  he  attended  school  for  five  years,  but 
made  little  progress;  he  drank  alcoholic  liquors  to  excess  and 
sometimes  was  drunk  two  or  three  times  a  week;  he  had  gonor- 
rhea several  times  and  a  chancre  a  year  previous  to  his  admis- 
sion; he  was  arrested  on  account  of  a  brawl  and  sent  to  the 
workhouse,  where  his  mental  condition  was  recognized  as  ab- 
normal. From  there  he  was  sent  to  the  Hospital,  where  he  was 
excited;  he  said  that  another  inmate  had  shot  some  dope  or 
chloroform  into  him,  that  all  the  other  prisoners  were  dodging 
about  to  avoid  it,  this  was  blown  at  him  through  a  long  stem, 
and  he  could  not  sleep  and  felt  queer ;  he  believed  he  would  have 
been  killed  by  it  if  he  had  remained,  for  he  heard  them  talking 
about  ''kill  that  nigger,"  and  he  became  frightened  and  excited; 
bells  were  also  rung  in  his  ears,  voices  asked  him  how  he  felt; 
he  believed  some  one  was  after  him  trying  to  read  his  mind ;  he 
said  that  the  poisoned  stuff  which  was  being  shot  at  him  he 
could  feel,  smell,  and  taste,  but  could  not  see  the  dust  of  it,  and 
could  not  see  the  people;  some  nights  he  jumped  out  of  bed 
because  he  thought  electricity  was  being  used  upon  him  and  for 
several  days  he  had  the  feeling  of  things  crawling  over  his  body 
like  insects.  The  physical  and  neurological  examinations  re- 
vealed no  abnormalities  except  a  complete  positive  Wassermann 
of  the  blood  serum ;  he  was  uneducated,  and  his  general  informa- 
tion and  memory  were  poor,  but  he  exhibited  a  good  memory 
for  occurrences  in  his  own  life;  at  first  he  was  quiet  and  orderly; 


14  SHEPHERD  IVORY  FRANZ 

he  was  tidy  in  habits;  he  helped  with  the  ward  work;  he  ap- 
preciated his  surroundings;  he  answered  questions  promptly,  but 
talked  little  with  the  other  patients ;  and  he  appeared  to  be  some- 
what depressed.  Later  he  became  sullen;  he  stood  in  various 
places  about  the  ward;  he  was  slow  in  movements  and  showed 
a  tendency  to  remain  in  one  attitude  for  a  considerable  length 
of  time;  he  took  no  interest  in  what  went  on  about  him;  he 
never  spoke  unless  spoken  to;  he  was  disoriented  for  time  but 
oriented  for  place  and  persons;  he  had  auditory  hallucinations 
of  voices  which  seemed  to  come  from  his  stomach,  and  which 
were  interpreted  as  the  spirit  of  God  talking  to  him;  the  voices 
said  different  things,  but  he  could  not,  or  would  not,  recount  any 
particular  thing;  insight  was  lacking;  pulmonary  tuberculosis 
was  diagnosed  three  months  before  death. 

The  autopsy  showed:  pulmonary  and  intestinal  tuberculosis; 
fibrous  deposits  over  the  small  intestine,  and  infiltration  of  the 
mesenteric  glands;  slight  shrinkage  of  the  anterior  portions  of 
the  cerebrum,  but  no  other  gross  cerebral  lesions  on  section. 

Case  6,  white  male,  was  25  years  old  at  the  time  of  admission 
and  lived  28  years  subsequently. 

No  family  or  previous  personal  history  was  obtained  except 
that  the  patient  exhibited  mental  abnormalities  for  a  month  pre- 
vious to  his  admission;  during  his  Hospital  residence  he  became 
gradually  demented  and  exhibited  periodic  variations  in  his 
behavior.  At  one  time  he  would  be  quiet  and  orderly,  and  he 
would  sit  or  stand  for  hours  at  a  time  in  one  place ;  for  the  most 
part  he  was  tidy  in  his  habits;  he  seldom  answered  and  volun- 
teered no  information;  he  appeared  to  be  dull  and  stupid  and  in 
almost  a  semi-conscious  condition.  This  state  would  last  for  a 
week  or  two  and  be  replaced  by  one  of  general  activity ;  he  sang 
loudly  and  irrationally  nearly  all  night;  he  was  restless,  destruc- 
tive, and  imtidy  in  dress  and  habits;  he  ran  around  the  ward 
moving  or  picking  up  everything  he  could  reach.  At  times  his 
face  was  expressionless  and  at  other  times  he  appeared  to  be 
very  much  depressed ;  his  talk  was  unintelligible,  and  he  mumbled 
to  himself  continually;  it  was  judged  that  he  had  auditory  hal- 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      15 

lucinations  because  at  times  he  turned  his  head  suddenly  to  the 
right  or  left  and  muttered  unintelligibly  or  excitably  as  if  he 
were  talking  to  or  scolding  some  one;  some  of  his  mutterings 
which  were  heard  indicated  that  he  believed  some  one  was  after 
him  and  wished  to  harm  him;  he  showed  no  interest  in  his  sur- 
roundings ;  he  could  not  be  made  to  work ;  his  memory  was  poor. 
In  his  later  years  it  was  noted  that  he  "exhibited  no  marks  of 
intelligence";  he  either  did  not  understand  questions  or  could 
not  make  himself  understood ;  his  clothing  was  disheveled ;  he  was 
filthy  in  habits;  and  when  he  could  he  stole  from  his  fellow 
patients ;  the  only  reaction  which  was  often  elicited  when  he  was 
spoken  to  was  the  opening  and  closing  of  his  eyes. 

Death  was  due  to  pulmonary  tuberculosis ;  in  addition  to  this 
condition,  cardiac  atrophy  and  atrophy  of  the  anterior  portions 
of  the  cerebrum  were  noted  at  the  autopsy. 

Case  7,  white  male,  36  years  of  age  at  the  time  of  admission; 
had  exhibited  mental  abnormalities  for  4  or  more  years  previous 
to  his  admission,  and  lived  in  the  Hospital  for  7  years. 

This  patient  was  a  wife  murderer  who  showed  the  following 
evidence  of  insanity  immediately  after  his  imprisonment  for  hfe; 
he  was  melancholic;  he  was  unconscious  of  his  surroundings; 
he  answered  in  monosyllables  when  at  all;  part  of  the  time  he 
would  not  talk  and  he  was  noted  to  have  a  treacherous  disposition. 
Whether  or  not  the  murder  of  his  wife,  for  which  he  was  con- 
victed, was  due  to  paranoid  ideas  was  not  determined,  but  in  view 
of  his  later  history  this  seems  probable,  and  the  psychosis  may 
have  begun  many  years  previous  to  the  date  assigned  above. 
His  expression  was  dull  and  indifferent ;  his  attitude  was  stooped 
and  careless,  and  he  walked  in  an  apparently  reckless  and  slovenly 
manner.  Physical  and  neurological  examinations  showed  no 
abnormalities  of  importance.  On  admission  he  recognized  what 
was  said  to  him;  he  knew  where  he  was;  he  exhibited  a  fair 
memory ;  he  rubbed  his  hair  and  face,  twisted  his  mouth,  grinned 
meaninglessly  and  hummed  to  himself;  he  attempted  to  strike 
an  attendant  with  a  shoe ;  but  at  this  time  no  delusions  or  halluci- 
nations were  detected;  he  was  restless,  continually  moved  about 


i6  SHEPHERD  IVORY  FRANZ 

the  ward,  he  walked  rapidly  and  in  an  excited  manner ;  he  wanted 
his  own  way,  but  otherwise  was  apparently  indifferent  to  what 
went  on;  he  rarely  spoke  voluntarily,  but  sometimes  sang  to 
himself;  he  was  noisy  at  times  and  at  other  times  appeared  to  be 
depressed ;  he  was  clean  in  habits ;  he  butted  his  head  against  the 
door  and  walls  of  his  room;  false  hearing  was  suspected  on  ac- 
count of  his  frequent  talking  to  himself ;  he  used  abusive  terms 
towards  parts  of  the  room  in  which  no  one  was  present;  he 
would  not  tell  what  or  who  was  bothering  him;  he  shouted  vile 
names ;  he  answered  general  questions,  although  this  was  done  in 
a  surly  manner.  Later  his  hallucinations  and  delusions  became 
more  evident;  he  believed  that  a  woman  was  after  him,  that  she 
came  into  his  room  at  night  to  bother  him ;  he  called  to  her  out 
of  the  window,  using  a  number  of  names  indicating  her  indecent 
character;  he  also  bawled  at  some  chickens  which  he  believed 
were  on  the  floor  under  his  feet,  and  he  attempted  to  "shoo" 
them  away  and  to  stop  their  cackling;  a  month  later  a  swelling 
of  his  feet  and  legs  was  observed,  and  at  that  time  he  was  fre- 
quently found  on  his  hands  and  knees  on  the  floor  looking  under 
the  bed  for  the  dogs  which  he  believed  were  there  and  upon 
which  he  stepped;  at  this  time  he  admitted  having  auditory 
hallucinations  (of  voices)  ;  and  also  visual  hallucinations  (of 
ghosts  and  people)  when  he  closed  his  eyes;  he  assumed  catatonic 
attitudes;  he  exhibited  numerous  mannerisms,  and  at  times  had 
impulsive  outbreaks;  at  the  same  time  he  was  negativistic ;  he 
was  found  to  have  pulmonary  tuberculosis,  and  death  was  due 
to  this. 

In  addition,  the  autopsy  showed:  intestinal  tuberculosis  and 
some  shrinkage  of  the  cerebral  convolutions  anteriorly. 

Case  8,  white  male,  had  ex^hibited  mental  disturbance  for  more 
than  6  months  previous  to  his  admission;  he  was  aged  30,  and 
lived  2  years  and  8  months  in  the  Hospital. 

His  .family  history  was  negative;  the  patient  had  attempted 
a  criminal  assault  and  was  convicted  for  this;  in  the  last  few 
months  of  his  term  in  prison  he  developed  a  disorderly  tempera- 
ment ;  he  laughed  when  questions  were  asked ;  he  refused  to  wear 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      17 

clothing  and  to  obey  orders,  and  occasionally  to  eat.  The  physi- 
cal and  neurological  examinations  revealed  nothing  of  importance 
except  a  distended,  tympanitic  abdomen  and  stumbling  over  test 
speech  phrases.  On  admission  he  conversed  with  a  physician 
pleasantly,  but  appeared  to  be  suspicious;  he  had  notable  man- 
nerisms of  gritting  his  teeth  and  drumming  on  the  table  with 
his  fingers ;  he  was  neat  and  tidy ;  he  believed  his  family  had  been 
sent  to  the  same  prison  as  he;  at  times  he  became  irritable  and 
was  pugnacious,  especially  when  another  patient  walked  in  front 
of  him,  and  because  of  this  he  had  several  altercations  with  them ; 
he  expressed  the  belief  that  he  was  some  kind  of  a  Mason,  al- 
though he  had  not  been  initiated  into  or  by  a  regular  lodge,  but 
had  been  "admitted  through  another  personality" ;  his  replies  in- 
dicated that  he  believed  his  personality  changed  from  day  to 
day,  although  he  said  he  could  not  reveal  the  secret  of  this  be- 
cause it  was  Masonic  and  military;  in  general  he  was  well 
oriented  and  showed  fair  memory  and  considerable  general 
knowledge,  but  he  had  no  insight  into  his  condition;  he  refused 
to  answer  many  questions  on  the  ground  that  they  were  "too 
easy";  at  various  times  he  said  that  the  Government  owed  him 
money,  that  he  was  a  rich  man,  and  that  he  used  to  travel 
about  a  great  deal ;  he  continued  to  be  reticent  about  his  previous 
life  and  his  ideas,  but  was  cross  and  disagreeable;  he  refused 
medicine  and  food,  and  many  times  fought  with  the  attendants 
and  with  the  other  patients ;  hallucinations  of  any  kind  were  not 
recorded  as  having  been  evident;  he  frequently  complained  of 
abdominal  pain  and  suffered  from  distention  of  abdomen;  an 
operation  was  planned,  but  not  performed  on  account  of  the  sud- 
den death  of  the  patient  from  intestinal  obstruction  and  gangrene. 
In  addition  to  the  diseased  conditions  which  caused  his  death, 
the  autopsy  revealed  fatty  changes  in  the  liver  and  slight  shrink- 
age of  the  anterior  fKDrtions  of  the  cerebrum,  with  no  other  gross 
cerebral  lesions. 

Case  9,  white  male,  admitted  at  the  age  of  34  and  lived  nearly 
20  years  in  the  Hospital. 

The  mental  diagnosis  which  was  made  was  "probably  cerebral 
syphilis,"  but  later  this  was  changed  to  dementia  precox,  prob- 


i8  SHEPHERD  IVORY  FRANZ 

ably  paranoid  form.  The  certificate  on  entrance  stated  that  the 
patient  had  visual  hallucinations  and  delusions  of  persecution  but 
no  maniacal  explosions,  although  he  talked  incessantly  about  the 
loss  of  some  musical  instruments;  he  also  had  hallucinations, 
which  were  nocturnal  in  character,  of  seeing  women  coming  to 
the  beds  of  patients  who  were  in  the  same  ward  with  him.  He 
admitted  having  had  a  soft  chancre  at  eighteen,  and  gonorrhea  at 
nineteen ;  the  physical  examination  was  negative  except  for  irreg- 
ularities and  inequality  of  the  pupils;  there  was  no  disorder  of 
voluntary  movement,  or  of  the  reflexes  or  of  sensation;  there  were 
hypertrophy  of  the  heart  and  lesions  of  the  valves.  He  smiled  con- 
stantly, his  expression  was  dreamy  but  fairly  intelligent;  no 
peculiar  actions  were  noted;  he  reported  that  soon  after  his  ar- 
rival at  the  Hospital  he  was  given  some  black  medicine  which 
injured  his  health,  making  him  nervous  and  giving  him  pains  in 
the  legs  like  needles,  and  causing  him  to  spit,  which  made  his 
tongue  sore;  subsequently,  no  delusions  were  elicited  except  a 
brief  mention  of  this  supposed  poisoning  episode.  Thirteen  years 
after  his  entrance,  it  was  noted  that  he  was  not  depressed;  he 
talked  and  associated  with  the  other  patients;  he  played  games 
of  different  kinds  when  on  the  ward,  and  also  played  a  musical 
instrument;  he  sat  quietly;  he  was  not  overly  religious;  he  did 
not  assume  peculiar  attitudes;  he  was  tidy  in  habits;  he  did  not 
lack  in  initiative;  his  memory  for  recent  and  old  events  was 
good;  he  was  not  agitated  as  a  result  of  any  of  his  delusions;  he 
did  not  become  excited,  abusive,  profane,  destructive  or  untidy; 
he  slept  well;  his  conversation  was  coherent;  he  had  parole  of  the 
grounds;  he  was  well  oriented;  he  appeared  to  be  content;  he 
never  complained,  and  he  played  in  the  Hospital  band.  On 
several  occasions  later  he  became  restless  and  very  much  con- 
fused, being  unable  to  comprehend  what  was  said  to  him  and 
seeming  to  be  much  disturbed ;  one  of  these  attacks  immediately 
preceded  his  death.  During  the  later  years  of  his  life  he  showed 
marked  loss  of  intelligence  and  very  little  judgment;  it  was  diffi- 
cult to  get  his  attention,  and  when  his  attention  was  obtained, 
it  was  almost  impossible  to  hold  it ;  he  showed  much  retardation ; 
he  spoke  indistinctly,  and  at  times  his  teeth  were  kept  closed  so 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      19 

that  it  was  difficult  to  understand  what  he  said;  he  also  seemed 
unable  to  comprehend  some  of  the  simplest  questions,  and  when 
asked  to  repeat  one  which  had  been  asked,  he  was  unable  to  do 
so;  he  remained  orderly,  but  took  no  interest  in  his  surroundings; 
he  was  neat  and  tidy;  he  was  also  fairly  well  oriented  in  all 
spheres ;  he  had  fair  memory  of  his  personal  history,  but  of  other 
events  his  memory  was  very  poor. 

Death  was  due  to  cardiac  valvular  disease.  The  autopsy 
showed  that  he  had:  hypertrophied  heart;  marked  aortic  ather- 
oma ;  mitral  aortic  valves  contracted ;  pulmonary  tubercular  scars 
and  pulmonary  hypostasis;  nutmeg  liver;  some  adhesions  in  the 
region  of  the  appendix;  brain  shrinkage  over  the  anterior  two- 
thirds  of  the  convolutions,  but  no  other  cerebral  lesions;  and  a 
slight  sclerosis  of  the  large  vessels  at  the  base. 

Dementia  Precox,  Discussion 
Although  these  nine  cases  have  somewhat  different  clinical 
symptoms,  the  symptomatology  of  all  is  sufficiently  alike  to  war- 
rant the  clinical  diagnosis  of  dementia  precox.  The  form  of 
the  disease,  it  should  be  remarked,  is  not  the  same  in  all  cases, 
five  being  judged  to  be  catatonic  (3,  4,  5,  6,  and  7),  and  two  to 
be  paranoid  (i  and  8).  Cases  2  and  9  were  committed  to  the 
Hospital  many  years  ago.  The  case  histories  of  these  patients 
contained  no,  or  very  meagre,  information  regarding  their  mental 
conditions  previous  to  commitment,  and  only  outlines  of  their 
behavior  during  their  early  hospital  residence.  We  are  not  en- 
tirely justified  in  making  a  definite  diagnosis  of  the  form  of 
precox  from  the  information  obtained  in  their  later  years,  but 
the  general  diagnosis  of  precox  is,  however,  justified  by  the  ac- 
counts which  have  been  kept,  and  the  symptoms  recorded  in  the 
records  during  their  later  years  might  be  interpreted  to  indicate 
that  case  2  was  a  paranoid  case,  and  case  9  an  hebephrenia. 

Looking  at  these  cases  from  another  point  of  view,  it  will  be 
noted  that  the  anatomical  lesions  do  not  correspond  with  the 
clinical  forms.  Of  the  three  cases  in  which  the  brain  was  noted 
to  have  shown  frontal  atrophy  one  was  diagnosed  as  paranoid,  a 
second  as  an  hebephrenic  and  the  third  was  a  "possible  paranoid" 


20  SHEPHERD  IVORY  FRANZ 

case.  Of  the  five  cases  with  anterior  atrophy  the  mental  diagno- 
sis of  catatonia  was  made  in  four,  while  the  fifth  was  a  paranoid 
case.  The  ninth  case,  with  atrophy  covering  the  anterior  two- 
thirds  of  the  cerebral  convolutions  was  the  case  mentioned  above 
as  possibly  hebephrenic.  The  only  evidence  of  a  possible  corre- 
lation between  the  forms  of  precox  and  the  character  of  the 
cerebral  atrophy  is  the  fact  that  most  of  the  cases  of  lesions  of 
the  anterior  convolutions  are  catatonic.  This  might  be  taken  to 
indicate  that  motor  disturbances  in  catatonia  may  be  associated 
with  pathological  changes  in  the  anterior  portions  of  the  cere- 
brum, but  case  8,  whose  brain  also  exhibited  similar  lesions  did 
not  exhibit  these  behavior  disorders.  It  should  also  be  remem- 
bered that  case  9,  in  whom  the  atrophy  covered  slightly  more  of 
the  cortex  than  in  the  catatonics  did  not  exhibit  motor  disturb- 
ances of  the  nature  of  catatonia.  These  two  cases  (8  and  9)  are 
sufficiently  definite  to  prevent  a  generalization  regarding  the  re- 
lations of  such  anterior  lesions  with  motor  disturbances  of  the 
nature  of  catatonia  or  negativism. 

During  their  Hospital  residence  all  of  these  patients  were 
noted  to  show  gradual  mental  deterioration,  although  the  amount 
of  this  decadence  differed  in  the  individual  cases.  The  histories 
show  that  cases  2,  3,  4,  6,  and  9  showed  towards  the  end  less 
evidence  of  being  thinking  beings  than  the  other  four  cases 
showed.  Excluding  case  4,  whose  age  at  the  time  of  death  was 
seventy-two,  and  whose  lack  of  mentality  might  have  been  due  to 
the  natural  decadence  associated  with  old  age,  the  other  four  cases 
are  not  chronologically  aged,  and,  in  fact,  of  the  other  cases 
there  were  two  (i  and  7)  whose  ages  were  respectively  greater 
than  those  of  cases  3,  6,  and  9,  and  case  3.  While  the  degree  of 
atrophy  in  these  five  cases  is  not  specified,  even  roughly,  there  is 
nothing  to  indicate  any  definite  relation  between  the  greater  men- 
tal deterioration  and  the  degree  of  atrophy.  It  is  true  that  the 
brains  of  cases  i,  5,  and  8  are  described  as  showing  only  "slight" 
atrophy,  but  case  7,  in  whom  extreme  mental  changes  were  not 
found  was  also  described  as  showing  "some"  atrophy,  which  term 
may  be  interpreted,  as  I  interpret  it  here,  to  indicate  only  a 
medium  degree,  rather  than  a  slight  degree.     No  mathematical 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      21 

estimation  has  been  made  in  the  individual  cases  regarding  either 
atrophy  or  mental  deterioration,  and  the  data  at  hand  do  not 
permit  the  correlation  of  these  two  conditions  at  the  present  time. 

It  is,  however,  of  interest  and  importance  to  note  that  the 
degree  of  dementia  in  those  cases  in  which  the  frontal  lobes  were 
atrophied  did  not  differ  to  any  appreciable  extent  from  those 
cases  in  which  the  atrophic  regions  were  larger.  Thus  case  2 
has  been  described  as  exhibiting  no  knowledge  of  things  occur- 
ring about  him,  and  case  3  to  have  "very  little  mental  capacity," 
although  the  latter  patient  at  the  time  of  his  death  was  only  forty- 
two  years  old.  In  addition,  it  has  been  noted  that  case  i  had  a 
poor  memory. 

Although  the  degree  of  dementia,  or  mental  abnormality,  does 
not  appear  to  be  directly  correlated  either  with  the  extent  or  with 
the  degree  of  the  atrophy  in  the  cases  which  we  have  studied,  we 
may  seek  for  correlations  in  the  individual  mental  symptoms. 
Differing  in  the  individual  cases,  and  giving,  as  they  do,  special 
characteristics  to  the  disease,  the  mental  symptoms  can  not  be 
dealt  with  in  great  detail.  Nor  can  the  individual  elements  of 
the  mental  processes  be  considered,  for  in  the  clinical  histories 
the  complex  mental  states  or  processes  have  not  been  analyzed 
into  their  elements.  This  is,  however,  not  different  from  the 
methodological  condition  found  in  most  clinical  work,  e.g.,  in 
neurology,  and  the  attempts  at  correlation  of  the  complex  proc- 
esses with  cerebral  lesions  may  therefore  well  be  attempted  re- 
gardless of  the  lack  of  analysis  of  these  complexes. 

Underlying  all  diagnostic  methods  in  psychiatry  are  the  as- 
sumptions that  mental  states  are  mirrored  by  acts,  that  acts 
change  in  accordance  with  the  mental  states,  and  that  changes  in 
mentality,  which  are  supposed  to  be  produced  by  or  correlated 
with  functional  or  anatomical  cerebral  lesions,  are  evidenced  by 
alterations  in  general  behavior.  In  their  general  form  these  as- 
sumptions may  be  satisfactory,  but  when  they  are  made  more 
specific  they  become  open  to  criticism.  In  the  cases  which  have 
been  described  above  this  latter  appears  to  be  true.  It  will  be 
noticed  that  four  of  these  patients  have  been  described  as  tidy 
in  habits,  while  four  others  have  been  described  as  untidy  or 


22  SHEPHERD  IVORY  FRANZ 

filthy,  while  the  ninth  has  not  been  specifically  described  but  ap- 
pears to  have  been  tidy.  Two  of  the  untidy  patients  were  those 
in  which  only  the  frontal  regions  were  atrophied,  and  two  in 
which  the  anterior  lobes  were  shrunken.  Case  9,  in  whom  the 
atrophy  extended  farther  backwards  than  in  the  other  eight 
cases,  was,  however,  noted  to  be  tidy.  In  this  respect  there  is 
correlation  neither  with  the  extent  nor  with  the  degree  of  the 
atrophy. 

Although  the  frontal  lobes  are  believed  to  have  more  direct 
relations  with  motor  processes,  the  data  at  hand  regarding  the 
motor  manifestations,  other  than  the  catatonic  attitudes,  etc., 
in  these  patients  do  not  appear  to  be  correlated  with  the  lesions. 
A  comparison  of  the  movement  differences  in  the  patients  under 
consideration  shows  that  the  variations  are  not  variations  cor- 
responding with  the  regional  atrophies.  Certain  of  the  patients 
varied  from  a  quiet  to  a  restless  state;  others  were  almost  con- 
tinually restless  or  noisy;  and  two  were  noted  to  be  uniformly 
slow,  unresponsive,  and,  during  part  of  the  time,  motionless. 
Some  may  be  inclined  to  interpret  the  general  motor  manifesta- 
tions to  be  evidence  of  a  supposed  inhibition  function  of  the 
frontal  regions  of  the  brain,  in  some  of  the  cases  there  being  a 
greater  amount  of  inhibition,  and  in  others  a  lesser  amoimt  of 
inhibition  than  in  normal  individuals.  The  fact  that  the  vari- 
ations were  not  always  in  the  same  direction  in  the  different 
patients,  would,  however,  be  a  matter  needing  special  explanation 
in  addition  to  the  general  hypothesis.  We  should,  on  the  basis 
of  our  present  knowledge  of  the  motor  functions  of  the  cortex, 
be  able  to  explain  or  to  correlate  these  irregular  weekly  or 
monthly  variations  in  activity  in  the  same  patient  with  exaccerba- 
tions  in  irritation  or  degeneration  of  the  ganglion  cells,  but  the 
pathological  facts  which  would  warrant  such  explanations  or 
correlations  are  lacking.  One  element,  which  appears  to  the 
writer  to  be  important  in  this  connection  is  that  the  motor  phe- 
nomena in  the  cases  under  consideration  did  not  differ  very 
greatly.  If  these  motor  disorders'  were  due  principally  to  the 
pathological  conditions  of  the  cells  in  the  atrophic  areas,  we 
should  expect  to  find  greater  motor  disturbances  associated  with 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      23 

those  atrophies  which  were  of  the  greatest  extent,  or  at  least  we 
should  expect  that  the  motor  activities  in  those  patients  in  whom 
the  precentral,  or  physiological  motor,  area  was  involved  should 
be  more  greatly  changed  than  in  those  in  which  only  the  frontal 
lobes  were  atrophied.  Such,  however,  is  not  the  case.  There  is, 
as  has  been  written  above,  no  apparent  difference  between  the 
motor  derangements  in  those  patients  with  frontal  lesions  and 
those  with  lesions  which  also  involved  the  precentral  areas,  nor 
even  between  the  motor  phenomena  in  the  case  with  frontal 
lesions  and  those  in  the  one  case  in  which  the  atrophy  also  in- 
volved the  precentral  areas  and  parts  of  the  parietals  in  addition 
to  the  frontals. 

Certain  clinico-neurological  facts  have  been  interpreted  to 
mean  that  the  activities  of  the  frontal  lobes  are  especially  asso- 
ciated with  emotional  states  or  emotional  expression,  and  were 
this  true,  different  degrees  of  frontal  lesions  might  be  expected 
to  result  in  variations  in  emotional  tone  or  in  the  character  of 
the  affective  conditions.  In  these  nine  cases,  however,  the  emo- 
tional conditions  were  somewhat  similar,  in  that  it  was  variable 
in  all.  It  varied  from  depression  to  indifference,  and  occasion- 
ally to  a  high  degree  of  happiness.  Many  of  the  affective  states 
in  these  patients  depended  upon,  or  resulted  from,  or,  to  speak 
accurately,  accompanied,  and  corresponded  with,  delusions,  and 
it  is  not  possible  to  separate  the  affective  elements  from  these 
other  mental  states.  Neither  the  degree  nor  the  extent  of  the 
cerebral  changes  appears  to  be  correlated  with  the  intensity, 
character  or  variability  of  the  affective  states,  for  the  fear  and 
suspiciousness  of  cases  i  and  5,  in  which  only  slight  atrophies 
respectively  of  the  frontal  and  anterior  convolutions  were  noted, 
did  not  differ  from  similar  states  in  patients  3  and  7,  whose 
brains  showed  corresponding  areal  distributions,  but  with  slightly 
increased  degrees,  of  atrophy.  An  examination  of  the  case  his- 
tories also  shows  that  the  fluctuations  from  one  affective  state 
to  another  is  not  associated  with  particular  degrees  or  extents  of 
the  lesions. 

Notable  variations  both  in  the  presence  and  in  the  characters  of 
hallucinations  were  also  recorded.     Of  the  nine  patients,   four 


24 


SHEPHERD  IVORY  FRANZ 


exhibited  plain  evidence  of  auditory  hallucinations  (cases  i,  2, 
5,  and  7).  Two  others  (cases  4  and  6)  appear  to  have  had  audi- 
tory hallucinations,  although  this  is  not  as  certain  as  in  the  other 
four  cases.  The  presence  of  auditory  hallucinations  in  case  4 
has  been  inferred  from  his  talking  to  himself,  and  similarly  in 
case  6  because  he  mumbled  to  himself  and  because  he  had  been 
noted  to  turn  his  head  towards  a  special  part  of  the  room  and 
app>eared  to  listen  when  no  one  was  present  there.  Definite  evi- 
dence of  visual  hallucinations  was  found  in  only  two  of  the  cases; 
viz.,  patients  7  and  9,  and  in  one  of  these  it  has  been  noted  they 
were  more  frequently  present  at  night.  Patients  i  and  7  also 
exhibited  actions  which  were  interpreted  to  mean  that  they  had 
tactual  hallucinations  or  paresthesias.  Patient  i,  it  will  be  re- 
membered, reported  that  she  could  give  out  electrical  power,  and 
that  electric  currents  had  been  turned  upon  her.  Patient  7  com- 
plained of  chickens  and  dogs  which  he  thought  were  in  his  room 
and  which  he  was  compelled  to  step  upon  when  he  got  out  of  his 
bed.  Whether  or  not  the  latter  case  is  a  mixed  hallucination, 
e.g.,  tactual  and  visual,  was  not  determined.  The  actions  of  the 
patient  indicated  that  he  did  not  see  the  animals,  for  he  searched 
for  them  under  his  bed.  Case  3  was  reported  to  have  had  hal- 
lucinations previous  to  his  entrance  to  the  hospital,  but  during 
his  Hospital  residence  these  were  not  discovered.  In  the  case 
history  of  patient  8,  in  whose  brain  the  atrophy  extended  over 
the  anterior  portions,  no  hallucinations  were  recorded  at  any 
time. 

With  the  exception  of  cases  3  and  4,  these  patients  were  noted 
to  have  delusions.  It  may  not  be  definitely  stated  that  patient  3 
did  not  have  a  delusion  of  any  kind,  for  there  is  internal  evi- 
dence in  his  case  history  that  mental  abnormalities  of  this  kind 
may  have  been  present.  It  is  stated,  for  example,  that  in  the 
year  preceding  his  commitment  to  the  Hospital  he  was  restless 
and  melancholy  and  exhibited  extreme  anxiety.  The  reasons  for 
these  affective  states  are  not  mentioned,  but  it  appears  doubtful 
that  they  were  independent  of  ideas  of  impending  harm,  or  of 
persecution  or  the  like.  None  of  his  actions  during  his  Hospital 
residence  was  indicative  of  the  presence  of  a  delusion,  although 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      25 

during  those  years  he  was  observed  to  fluctuate  between  excite- 
ment and  mutism.  Case  4  was  also  judged  to  be  free  from 
delusions  during  the  period  of  his  Hospital  residence,  although 
the  general  facts  regarding  his  mental  condition  for  21  years 
previous  to  his  admission  are  not  sufficient  to  warrant  the  state- 
ment that  delusions  had  not  been  present  during  that  period  of 
time.  The  considerable  degree  of  dementia  which  was  present 
during  his  Hospital  residence  may  have  made  the  expression  of 
delusions  difficult,  but  his  reactions  to  the  auditory  hallucinations 
from  which  he  suffered  would  not  lead  to  this  conclusion.  The 
characters  of  the  delusions  of  the  other  seven  cases  ranged  over 
the  fields  of  somatopsychic,  autopsy  chic,  and  allopsychic.  De- 
lusions of  persecution  were  the  more  frequent,  but  these  alter- 
nated with  delusions  of  grandeur  in  some  cases.  None  of  the 
somatopsychic  delusions  was  definitely  associated  with  corre- 
sponding pathological  physical  conditions,  with  the  possible  ex- 
ception of  those  of  case  7.  This  patient  complained  that  chickens 
and  dogs  were  on  the  floor  of  his  room,  and  that  he  had  to  step 
upon  them  when  he  rose  from  his  bed.  The  physical  condition 
associated  with  this  delusion  was  a  swelling  of  the  feet,  and  as 
has  been  suggested  above,  the  hallucinations  and  the  delusion 
may  have  resulted  from  the  stretching  of  the  skin.  The  as- 
sociation of  the  different  characters  of  delusions  with  the  cere- 
bral atrophies  in  these  cases  is  neither  constant  nor  definite,  cases 
3  and  4  belonging  respectively  to  the  frontal  and  anterior  atrophy 
groups,  so  that  we  are  forced  to  the  conclusion  that  the  lesions 
can  not  be  constantly  associated  with  delusion  formation.  These 
results  are  of  interest  in  connection  with  Southard's  studies  of 
delusions  and  especially  with  his  conclusion  that  the  presence  of 
delusions  is  "to  be  correlated  more  with  lesions  of  the  anterior 
association  center."^ 

Regarding  the  conditions  of  memory  in  these  patients  there  is 
httle  information.  Six  of  them  were  unable  to  recount  recent 
events  or  events  in  their  own  lives,  or  were  unable  to  repeat 
simple  questions  which  had  previously  been  asked.     The  other 

*  Southard,  E,  E.  The  (Mind  Twist  and  Brain  Spot  Hypotheses  in  Psycho- 
pathology  and  Neuropathology.  Psych.  Baill.,  1914,  11,  1 17-130.  See  espe- 
cially p.  123,  and  other  references  there  given. 


26  SHEPHERD  IVORY  FRANZ 

three  cases  exhibited  a  fair  degree  of  memory.  Whether  these 
apparent  memory  defects  were  due  to  lack  of  attention  or  to 
inability  to  retain  the  impressions  which  were  received  can  not 
be  decided.  All  the  patients  with  simple  frontal  lesions,  irre- 
spective of  the  degree  of  atrophy,  had  poor  memory,  whereas 
patients  4,  7,  and  8  with  anterior  atrophies  exhibited  fair  memory. 

In  contrast  to  the  memory  defects  of  these  patients  the  degree 
of  orientation  is  to  be  noted.  Although  orientation  depends,  at 
least  to  a  certain  extent,  upon  retention,  it  is  not  necessarily  as- 
sociated with  general  memory  ability.  This  is  shown  in  case  9 
where  memory  appeared  to  be  very  defective,  although  he  was 
fairly  well  oriented  in  all  spheres,  and  in  case  5  who,  although 
disoriented  for  time,  was  oriented  for  place  and  persons.  On 
the  other  hand  patient  4,  who  exhibited  a  fair  degree  of  memory, 
had  no  grasp  of  his  surroundings.  The  relation  of  orientation 
ability  to  the  lesions  in  the  nine  cases  is  not  definite,  case  i  being 
opposed  in  this  particular  to  cases  2  and  3,  and  cases  5,  7,  and 
8,  showing  good  orientation  while  the  corresponding  cases,  4  and 
6,  were  in  general  disoriented.  Case  9,  in  which  the  atrophy  ex- 
tended beyond  the  anterior  region,  was  also  noted  to  be  fairly 
well  oriented. 

The  ability  of  the  patients  to  attend  to  stimuli  is  not  mentioned 
in  all  of  the  case  histories,  but  reading  between  the  lines,  it  is 
evident  that  this  was  poor.  It  is  possible  that  some  of  the  ap- 
parent memory  defects  were  due  to  lack  of  attention,  and  that 
certain  of  the  other  mental  disturbances  were  also  caused  by  the 
failure  to  attend  to  stimuli.  It  is  also  possible  that  the  degree  of 
dementia  is  correlated  to  a  certain  extent  with  the  failure  to 
attend. 

When  the  facts  of  atrophy  and  the  facts  of  mental  abnormali- 
ties in  these  nine  patients  are  taken  together,  it  is  seen  that  there 
are  decided  differences  in  the  character  of  the  psychic  symptoms 
associated  with  similar  cerebral  lesions.  It  is  also  apparent  that 
regardless,  of  the  extent  of  the  atrophies  similar  mental  symp- 
toms may  be"  evidenced.  The  conclusion  that  follows,  therefore, 
is  that  similar  cerebral  lesions  in  cases  of  dementia  precox  do 
not  always  result  in  similar  forms  of  the  disease,  nor  in  similar 
symptoms  in  all  individuals,  nor  in  the  same  degree  of  dementia. 


GENERAL  PARALYSIS  OF  THE  INSANE,   CLINICAL 

HISTORIES 

Case  10,  colored  male,  was  admitted  to  the  Hospital  at  the  age 
of  30,  and  lived  over  4j^  years. 

There  is  nothing  of  importance  in  the  patient's  family  history, 
and  the  only  facts  of  interest  in  his  personal  history  is  that  he 
admitted  gonorrhea,  denied  having  had  syphilis,  and  admitted 
that  he  had  used  alcoholic  liquors  since  he  was  a  boy,  but  said 
he  had  never  been  drunk.     The  physical  examination  revealed 
nothing  of  interest,  except  that  there  was  a  complete  positive 
Wassermann  of  the  blood  serum  and  a  trace  of  the  reaction  in 
the  cerebrospinal  fluid.    He  had  diminished  knee  jerks,  sluggish 
reactions  and  inequalities  of  the  pupils,  well-marked  tremor  of 
the  tongue,  lips  and  facial  muscles ;  speech  was  somewhat  ataxic, 
and  there  was  difficulty  in  repeating  test  phrases.    The  onset  of 
the  mental  disturbance  appeared  to  be  a  sudden  one;  he  had 
been  working  as  a  waiter  two  days  before  his  arrest;  he  said 
he  had  found  a  check  which  called  for  $30,000,000,  on  the  back 
of  which  there  was  a  notice  to  return  it  to  the  bank  and  receive 
$1,000,000  for  it;  the  bank  was  closed  but  he  showed  it  to  a 
number  of  people  and  tried  to  get  $300  for  it;  one  man  gave 
him  $500  for  it,  but  a  policeman  arrested  the  patient,  took  him 
to  a  hospital  and  later  he  was  brought  to  this  institution.    How 
much  of  the  above  incident  was  based  upon  a  minimum  of  fact 
was  not  determinable.     On  entrance  his  expression  was  one  of 
exaltation;  he  was  quiet  and  cheerful;  his  habits  were  tidy;  he 
gave  no  trouble  except  slightly  by  constantly  requesting  that  he 
be  permitted  to  be  allowed  to  go  out  so  that  he  could  get  his 
money;  he  was  well  oriented  for  time,  place,  and  persons;  his 
attention  could  easily  be  attracted  and  held;  he  comprehended 
what  was  said  to  him,  and  answered  coherently  and  relevantly, 
except  when  his  delusional  ideas  were  touched  upon,  whereupon 
he  became  rambling  and  disconnected  in  conversation;  his  mem- 


28  SHEPHERD  IVORY  FRANZ 

ory  for  recent  and  remote  events  was  good  for  one  of  his  grade 
of  intelligence ;  his  emotional  tone  was  one  of  exaltation,  he  was 
as  "happy  as  a  lark";  he  was  sociable  with  the  other  patients 
and  worked  on  the  ward;  no  hallucinations  could  be  elicited. 
Later,  he  had  a  period  of  confusion  for  a  few  hours,  in  which 
he  took  the  dishes  from  the  table  and  placed  them  outside  of 
the  window  (reporting  that  he  thought  thereby  he  would  get 
some  tobacco),  and  attacked  one  of  the  nurses  and  demanded 
his  keys;  his  delusions  of  wealth  had  not  changed  materially; 
subsequently  he  had  convulsions,  was  then  confined  to  bed,  and 
developed  contractures.  At  that  time  he  spoke  rarely  and  then 
only  a  few  phrases,  he  took  no  cognizance  of  what  went  on 
and  led  a  nearly  vegetable  existence  till  his  death  from  exhaus- 
tion of  paresis.  The  autopsy  showed  that  the  cerebral  convolu- 
tions over  the  frontal  regions  were  shrunken. 

Case  II,  colored  male,  had  been  known  to  have 
mental  abnormalities  ior  at  least  7  months  prior  to  his  ad- 
mission at  the  age  of  37,  and  he  lived  for  nearly  2  years  in  the 
Hospital. 

His  family  and  personal  history  were  not  obtained  in  any 
detail,  for  he  could  not  give  much  information  and  what  he  gave 
appeared  to  be  rather  unreliable.  He  denied  a  syphilitic  history, 
but  was  found  to  have  a  scar  on  his  penis  due  to  an  old  sore ;  the 
Wassermann  reaction  with  the  blood  serum  was  complete  posi- 
tive, with  the  cerebrospinal  fluid  a  trace,  the  number  of  cells  in 
the  cerebrospinal  fluid  was  170  per  cu.  mm.  The  neurological 
examination  showed  marked  tremors  of  the  tongue  and  fingers, 
and  somewhat  generally  throughout  the  body;  station  and  gait 
were  tremulous  and  impaired,  he  was  unable  to  stand  on  one  leg; 
coordination  was  impaired;  there  was  a  marked  speech  defect; 
some  of  the  reflexes  were  diminished,  others  were  absent;  the 
pupils  were  unequal  and  reacted  only  slightly  to  stimuli.  He 
appeared  to  be  contented  and  did  not  seem  to  worry ;  he  sat  in  a 
listless,  though  cheerful,  mood,  and  paid  little  attention  to  his 
surroundings ;  he  did  not  appear  to  be  oriented ;  he  obeyed  simple 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      29 

commands,  but  when  questioned  he  did  not  answer  at  times; 
he  was  tidy  in  his  dress  and  in  his  habits  and  did  not  conflict  with 
his  surroundings;  he  beheved  he  owned  a  race  horse  for  which 
he  had  paid  $3,000.  He  had  a  brief  attack  of  unconsciousness 
followed  by  a  period  of  confusion  in  which  he  talked  to  himself 
and  made  signs  with  his  hands.  Physically  and  mentally  he 
declined,  until  he  was  unable  to  do  anything  for  himself;  he 
replied  to  no  questions,  and  was  apparently  oblivious  of  his 
surroundings.  Death  was  due  to  exhaustion  of  paresis.  The 
autopsy  also  revealed  pulmonary  tuberculosis,  pericarditis, 
atrophy  of  the  heart  valves,  fatty  degeneration  of  the  liver, 
chronic  cystitis,  and  general  shrinkage  of  the  frontal  lobes.  The 
microscopical  examination  showed  that  the  frontal  and  central 
convolutions  exhibited  the  characteristic  pictures  of  paresis,  but 
that  the  parietal  lobes  did  not  show  any  marked  changes. 

Case  12,  white  male,  had  been  suffering  from  mental  disease 
for  at  least  a  year  previous  to  his  admission  at  the  age  of  5 1 ; 
he  lived  2  years  and  8  months  after  his  admission. 

The  only  fact  of  interest  in  the  family  history  was  that  his 
mother  had  died  of  pulmonary  tuberculosis  when  the  patient  was 
eight  months  old.  He  received  a  high  school  education,  and  after 
serving  for  eight  years  in  the  army,  was  a  clerk.  He  had  con- 
tracted syphilis  thirty  years  previous  to  his  admission  and  had 
gonorrhea  at  a  later  period,  but  subsequently  married  and 
begot  three  healthy  children;  he  used  tobacco  to  excess.  About 
a  year  previous  to  his  admission  he  became  mentally  fatigued 
very  easily,  his  memory  was  impaired ;  he  could  not  comprehend 
as  well  as  he  formerly  could;  his  speech  became  indistinct;  his 
writing  was  careless,  showing  many  omissions  and  mistakes  in 
spelling ;  his  gait  was  ataxic.  At  the  same  time  he  became  morose, 
sullen  and  irritable;  he  worried  over  the  state  of  his  health; 
he  made  remarks  about  killing  the  members  of  his  family  and 
himself ;  he  also  bought  immense  quantities  of  perfumed  soap  and 
bathed  constantly.  The  neurological  examination  showed 
coarse  tremors  of  the  facial  muscles  and  twitchings  of  the  thigh 
muscles;  Romberg  sign  was  present;  gait  was  unsteady;  the 


30  SHEPHERD  IVORY  FRANZ 

knee  jerks  were  not  elicited;  the  Wassermann  reaction  with  the 
cerebrospinal  fluid  was  complete  positive ;  the  number  of  cells  per 
cu.  mm.  was  20.  On  entrance  to  the  Hospital  he  appeared  to 
be  cheerful,  contented  and  appreciative;  but  was  inclined  to 
be  fault-finding  with  his  surroundings  and  fretful  that  he  was 
not  permitted  to  have  all  his  clothes  and  his  special  toilet  articles 
in  his  room ;  he  kept  busy  washing  his  hands  and  face  and  comb- 
ing his  hair ;  he  appeared  to  be  bewildered  at  times,  and  expressed 
the  belief  that  he  had  offended  some  one  and  he  worried  about 
this;  in  general,  he  showed  no  interest  in  what  went  on  about 
him;  his  memory  for  recent  and  remote  events  was  poor;  no 
evidence  of  the  existence  of  hallucinations  or  delusions  was  dis- 
covered; his  habits  were  tidy;  he  was  usually  quiet,  but  at 
times  was  nervous.  Later,  fantastic  and  ridiculous  delusions  of 
a  grandiose  type  were  evidenced,  e.g.,  he  was  to  take  a  marvelous 
train  ride  through  the  country,  he  had  invented  things,  etc.  At 
times  he  became  worried,  he  wanted  to  shoot  a  fellow  patient, 
whom  he  believed  to  be  an  enemy ;  he  imagined  people  were  going 
to  do  something  mean  to  him,  that  they  came  to  take  away  his 
trunk  in  which  he  had  his  money,  he  also  spoke  of  being  tired  and 
explained  that  this  was  due  to  his  having  had  to  fight  negroes 
during  the  night;  he  became  untidy  in  habits.  The  depressive 
delusions  apparently  disappeared,  leaving  only  those  of  a  gran- 
diose type,  that  he  owned  the  Hospital,  had  immense  amount  of 
money,  etc.  He  became  much  demented,  he  was  bedridden,  con- 
tractures of  the  left  arm  and  leg  developed,  there  were  no  con- 
vulsions; death  was  due  to  exhaustion  of  paresis.  The  brain 
showed  great  atrophy  in  the  frontal  lobes. 

Case  13,  colored  male,  admitted  to  the  Hospital  at  the  age  of 
41,  lived  for  3  years  and  2  months  subsequently.  The  duration 
of  mental  disease  at  the  time  of  admission  was  about  2  years. 

The  family  history  was  negative.  The  medical  certificate 
stated  that  the  patient  had  had  syphilis;  mentally  he  had  a  vio- 
lent temper  and  was  very  irritable;  he  had  been  melancholy,  and 
had  exhibited  delusions  and  homicidal  tendencies.     Physical  ex- 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      31 

amination  showed  only  a  slight  heart  involvement,  Wassermann 
reactions  with  the  blood  serum  and  the  cerebrospinal  fluid  were 
positive,  there  were  65  cells  per  cu.  mm.  in  the  cerebrospinal 
fluid.  The  neurological  examination  showed  irregularities  in 
outline  of  the  pupils;  tremors  of  tongue,  lips,  eyelids,  and  ex- 
tended fingers ;  patellar  reflexes  were  very  much  diminished,  and 
there  was  a  Babinski  phenomenon  on  the  right;  his  station  was 
poor;  there  was  ihyperextension  of  the  legs  at  the  knee;  the  gait 
was  slightly  ataxic;  coordination  was  poor;  and  there  was  a 
marked  speech  defect.  His  facial  expression  was  placid ;  he  was 
orderly  and  quiet,  he  had  little  or  nothing  to  say  voluntarily; 
he  was  indifferent  and  inclined  to  be  stupid;  his  attention  was 
easily  obtained  and  held;  he  comprehended  questions  and  an- 
swered coherently  and  correctly,  but  slowly ;  he  was  not  oriented 
for  place,  time,  or  people;  his  memory  was  very  defective;  his 
judgment  was  poor ;  he  lacked  insight ;  emotionally  he  was  neither 
exalted  nor  depressed,  but  rather  indifferent  and  apparently 
satisfied;  he  did  not  associate  with  the  other  patients  and  mani- 
fested no  interest  in  his  surroundings ;  no  delusions  or  hallucina- 
tions could  be  elicited,  nor  were  they  judged  to  be  present  because 
of  his  conduct.  Later  he  was  restless,  disturbed  and  at  times 
noisy ;  he  talked  to  imaginary  people,  but  recognized  no  one  who 
saw  him;  dementia  became  profound;  he  comprehended  little; 
his  conversation  was  rambling  and  incoherent;  occasionally  he 
expressed  some  words  indicating  that  he  had  grandiose  ideas,  that 
he  possessed  houses  and  diamonds ;  at  times  he  became  disturbed 
and  noisy ;  and  often  was  restless,  destructive  and  filthy ;  when  he 
walked,  his  gait  was  very  ataxic.  The  autopsy  examination  re- 
vealed shrinkage  of  the  cerebral  convolutions,  especially  in  the 
anterior  parts. 

Case  14,  white  male,  was  admitted  at  the  age  of  33  years,  and 
lived  8  months;  his  mental  disease  was  evident  for  more  than  2 
months  previous  to  his  admission. 

The  medical  certificate  stated  that  the  patient's  father  died 
of  tuberculosis,  but  this  was  the  only  interesting  point  in  the 
family  history.     A  comrade  reported  that  the  patient  had  acted 


22  SHEPHERD  IVORY  FRANZ 

peculiarly  for  several  months.  The  patient  denied  that  he  had 
used  alcoholic  liquors.  He  showed  tremors  of  the  lips,  tongue 
and  hand,  difficulty  in  speaking,  some  impairment  of  intellect, 
muscular  weakness,  diminished  knee  jerks,  and  Romberg  sign. 
The  Wassermann  reaction  with  the  blood  serum  was  completely 
positive,  the  cerebrospinal  fluid  contained  145  cells  per  cu.  mm. 
On  admission  the  patient  would  not  talk,  and  his  lack  of  co- 
operation prevented  a  careful  examination  of  his  mental  condi- 
tion. He  had  a  very  stupid,  blank  expression,  stood  or  sat  in  a 
stiff,  unnatural  position  until  told  to  do  somethig;  several  times 
he  rose  from  his  chair  and  started  towards  the  window  as  if 
governed  by  some  idea,  but  at  command  he  readily  resumed  his 
seat;  jerkings  of  different  muscles  were  observed;  if  undisturbed, 
he  closed  his  eyes  as  if  going  to  sleep;  he  did  not  apparently 
know  how  to  hold  a  pencil  and  his  first  efforts  at  writing  were 
scribbles;  his  movements  at  unbuttoning  his  coat  were  inco- 
ordinate; there  was  no  evidence  of  apparent  purpose  fulness  in 
any  of  his  movements;  his  attention  was  obtained  and  held 
with  difficulty;  he  appeared  to  know  the  name  of  the  Hospital; 
on  account  of  his  non-cooperation  it  was  impossible  to  determine 
anything  about  the  character  of  his  memory,  or  the  presence 
of  hallucinations  or  delusions.  Later  it  was  noted  that  he  was 
tidy,  disoriented  for  time,  place  and  persons,  his  memory  was 
very  poor ;  he  could  not  find  his  bed,  etc. ;  he  did  not  answer 
questions  readily  and  seldom  talked.  He  was  confined  to  bed 
and  died  of  exhaustion.  The  autopsy  revealed  shrinkage  of  the 
anterior  cerebral  convolutions,  hypostatic  pneumonia,  intersti- 
tial nephritis  and  purulent  cystitis. 

Case  15,  white  male,  was  noted  for  one  month  previous  to 
his  admission  to  exhibit  signs  of  mental  abnormality;  his  age 
was  38,  and  he  lived  in  the  Hospital  for  i  year  and  6  months. 

The  family  history  obtained  from  the  patient  contained  noth- 
ing of  importance.  The  medical  certificate  accompanying  him 
stated  that  he  had  syphilis  six  years  previously,  but  this  was 
denied  by  the  patient;  the  Wassermann  reaction  with  the  blood 
serum  was  complete  positive,  also  with  the  cerebrospinal  fluid; 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      33 

the  number  of  cells  in  the  cerebrospinal  fluid  was  16.5  per  cu.  mm. 
The  patient  had  tuberculosis  during  his  residence  in  the  Hospital. 
Previous  to  his  admission  his  ward  mates  in  another  institu- 
tion had  complained  of  his  irrational  conduct  and  conversation. 
He  had  a  feeling  of  well  being  and  of  importance,  with  delusions 
of  grandeur,  but  no  delusions  of  persecution  or  hallucinations; 
in  addition  to  the  tuberculosis  it  was  found  that  the  patient's 
pupils  were  unequal,  the  left  reacted  neither  directly  nor  con- 
sensually  to  light  stimuli;  the  patellar  reflexes  could  not  be 
elicited;  coordination  was  good,  there  was  a  slight  Romberg 
sign  and  wavering  gait.  He  was  oriented  for  place  and  persons, 
and  mostly  for  time;  his  general  memory  was  poor  for  both 
recent  and  remote  events;  he  could  not  tell  the  times  and  places 
of  his  occupations;  he  showed  no  insight  into  his  condition  and 
said  he  thought  his  admission  into  the  Hospital  was  a  "frame- 
up";  an  occasional  slight  buzzing  in  his  left  ear  was  the  nearest 
to  an  hallucination  that  was  detected;  and  no  delusions  other 
than  that  recorded  above;  his  general  intelligence  was  poor;  he 
was  irritable,  easily  angered  when  questioned  and  swore 
fluently;  in  general,  he  appeared  to  be  happy;  he  emitted  loud 
screams  occasionally,  but  no  reason  for  these  could  be  obtained; 
his  writing  was  ataxic,  his  speech  was  tremulous ;  he  became  un- 
tidy in  habits ;  did  not  talk  voluntarily ;  he  became  much  demented 
and  enfeebled.  Death  was  due  to  pulmonary  tuberculosis.  The 
examination  of  the  brain  showed  that  the  convolutions  were 
shrunken  over  the  anterior  half. 

General  Paralysis  of  the  Insane,  Discussion 

Of  these  six  cases,  three  had  atrophies  in  the  frontal  region 
and  three  were  of  the  anterior  portions  of  the  cerebrum.  Only 
one  of  these  has  been  described  as  showing  a  great  degree  of 
atrophy,  viz.,  case  12.  All  of  these  patients  showed  a  very 
great  degree  of  dementia  previous  to  death.  The  one  who 
seemed  least  demented  was  case  13,  although  the  degree  of 
dementia  can  not  be  determined  with  accuracy.  It  is  of  interest 
to  note  that  the  total  duration  of  the  disease  in  this  patient 
was  longer  than  in  the  other  five  patients,  and  the  dementia 


34  SHEPHERD  IVORY  FRANZ 

appeared  to  be  more  gradual  in  its  appearance,  WHth  this 
case  there  should  be  compared  case  14,  who  lived  less  than 
a  year  after  the  first  signs  of  mental  abnormality.  Most  of 
these  patients  towards  the  end  lived  practically  a  vegetable  ex- 
istence; they  were  oblivious  of  their  surroundings;  they  reacted 
httle,  if  at  all,  to  ordinary  stimuli  and  were  apparently  unable 
to  comprehend  anything.  These  general  mental  conditions  which 
are  found  in  all  cases  of  paresis  are  not,  however,  correlated 
with  the  degree  or  with  the  extent  of  the  atrophy  of  the  brain, 
for  the  patient  (case  15)  whose  brain  showed  the  greatest 
amount  of  atrophy  was  no  more  demented  than  the  other  pa- 
tients at  the  time  of  death,  nor  was  the  patient  (case  12)  whose 
brain  showed  the  greatest  degree  of  atrophy  any  more  demented 
than  the  other  patients.  Both  of  these  cases  showed  an 
extreme  degree  of  dementia,  and  in  this  respect  they  differed 
not  at  all  from  the  other  cases  (with  the  possible  exception 
of  case  13,  which  is  mentioned  above). 

It  is  to  be  noted  that  all  of  the  patients  exhibited  motor  de- 
rangements. With  the  exception  of  case  15,  tremors,  especially 
of  the  lips,  tongue  and  hand,  were  found.  Case  15  did  not 
show  tremors  of  these  parts,  although  his  writing  was  tremulous 
and  associated  with  this  there  was  a  certain  degree  of  ataxia. 
It  does  not  appear,  however,  that  the  ataxic  gait  and  the  in- 
ability to  walk  steadily  and  to  perform  other  necessary  move- 
ments were  any  greater  in  those  patients  who  exhibited  lesions 
extending  beyond  the  frontal  lobes,  and  in  this  respect  we  find 
no  definite  correlation  between  the  atrophies  which  included 
the  electrically  excitable  {i.e.  motor)  portions  of  the  cerebrum 
and  those  which  did  not  extend  as  far  backwards.  Only  one 
of  the  six  patients  had  had  convulsions,  case  10,  and  this  pa- 
tient it  will  be  remembered  was  a  case  in  which  the  frontal 
regions  were  atrophied.  On  the  other  hand,  two  of  the  patients 
(cases  10  and  12)  developed  contractures,  and  it  is  of  interest 
to  note  that  both  of  these  were  cases  of  frontal  atrophy.  Periods 
of  confusion  or  of  bewilderment,  which  are  probably  similar  in 
nature  to  the  convulsive  seizures,  were  noted  in  cases  10,  11 
and  12,  and  in  one  of  these  (case  11)  such  a  condition  was  at 


SYMPTOM ATOLOGICAL  DIFFERENCES  IN  THE  INSANE      35 

one  time  preceded  by  a  period  of  unconsciousness.  These  three 
cases  were  those  in  which  only  frontal  lesions  were  discovered. 
The  affective  states  in  these  patients  were  not  similar.  In 
general,  although  they  appeared  contented,  some  had  feelings 
of  exaltation,  and  at  times  some  were  depressed.     Cases  10  and 

11  appeared  to  be  almost  continually  contented  and  cheerful. 
Case  15  appeared  to  have  feelings  of  contentment,  of  well-being, 
and  of  self-importance  at  practically  all  times,  and,  although  he 
complained  of  having  been  sent  to  an  institution  and  called  it 
ia  "frame-up,"  his  remarks  about  this  matter  appeared  to  have 
little  affective  accompaniment.  On  the  other  hand,  patient  14 
appeared  to  be  indifferent,  and  the  only  evidence  of  worry  or 
depression  on  his  part  was  his  disinclination  to  talk  and  his 
lack  of  cooperation.  The  reasons  for  the  impulsive  tendencies 
which  were  noted  in  his  case  were  not  learned,  but  these  were 
not  accompanied  by  noticeable  emotional  reactions.     Patients 

12  and  13  showed  variations  in  affectivity,  for  they  ranged  from 
sullenness,  moroseness  and  homicidal  tendencies  to  those  of 
cheerfulness  and  exaltation.  It  will  be  observed  that  these  varia- 
tions are  not  associated  with  particular  lesions,  and  that  similar 
variations  in  emotional  or  affective  states  are  found  associated 
with  the  more  extensive  as  well  as  with  the  frontal  atrophies. 

In  none  of  these  patients  were  hallucinations  noted  at  any 
time,  with  the  possible  exception  of  case  15,  who  had  complained 
of  a  buzzing  in  his  ear.  Whether  this  was  due  to  a  peripheral 
or  a  central  irritation  could  not  be  determined;  it  did  not  ap- 
parently lead  to  any  interpretative  elaboration,  and  because  of  this 
it  may  be  disregarded. 

Case  14  showed  no  evidence  of  the  presence  of  a  delusion  at 
any  time.  The  other  five  patients  were  noted  to  have. delusions 
of  grandeur  or  of  persecution,  although  these  were  most  fre- 
quently mild  in  character  and  those  of  some  of  the  patients  were 
not  much  beyond  the  scope  of  the  individual's  life.  In  a  few 
instances  the  delusions  were  of  a  very  fantastic  and  absurd  char- 
acter, notably  those  of  patient  10.  It  appears  remarkable,  how- 
ever, that  with  the  exception  of  the  temporary  and  unsystematized 


36  ^  SHEPHERD  IVORY  FRANZ 

delusions  regarding  the  race  horse  (case  ii),  the  possession  of 
houses  and  diamonds  (case  13),  and  some  of  grandeur,  of  which 
the  nature  was  not  specified  (case  15)  and  which  were  noted  only 
previous  to  his  entrance  to  the  Hospital,  these  evidences  of  mental 
abnormality  were  not  prominent  in  these  three  cases.  Moreover, 
it  may  be  mentioned  that  some  of  the  delusions  of  patient  12,  e.g., 
those  which  were  evidenced  by  his  complaints  that  various  people 
were  trying  to  get  his  money  away  from  him,  were  not  too  far 
out  of  bounds,  and  might  not  have  been  delusions  in  the  strict 
sense  of  that  term.  In  this  connection  it  must  also  be  remem- 
bered that  with  the  possible  exception  of  the  delusion  regarding 
his  retention  in  the  Hospital,  which  he  described  as  a  "frame-up," 
patient  15  did  not  show  any  evidence  of  delusions  during  his 
Hospital  residence  of  about  eighteen  months.  We  are  led  to  con- 
clude from  the  facts  which  have  been  recorded  that  these  mental 
symptoms  do  not  appear  to  be  concomitants  of  special  extent,  or 
of  special  degree,  of  atrophy  of  the  anterior  regions  of  the  brain, 
and  that  delusions,  in  cases  of  paresis  at  least,  may  not  be  due  to 
the  cerebral  changes  in  the  frontal  lobes. 

It  is  of  interest  to  note  that  in  these  cases  the  memory  dif- 
fered very  greatly.  Although  the  memory  of  all  was  very  poor 
during  the  later  weeks  or  months  of  their  Hospital  life,  in  some 
cases,  even  at  times  when  the  other  evidences  of  abnormality 
were  plain,  e.g.,  delusions,  it  was  noted  that  the  memory  for 
remote  and  recent  events  was  fair.  Thus,  case  10  appeared  to 
have  a  remarkably  good  memory  for  the  events  of  his  past  life 
and  even  for  other  events  which  did  not  so  immediately  concern 
him,  although  his  delusions  regarding  his  wealth  were  very  ab- 
surd and  in  this  respect  his  judgment  was  very  defective.  Re- 
garding case  14,  no  information  could  be  obtained  on  account  of 
his  lack  of  cooperation.  The  memory  in  the  other  four  cases 
may  be  said  to  correspond  in  general  with  the  degree  of  de- 
mentia, although  not  with  the  extent  or  the  degree  of  the  atrophy. 

In  most  cases  the  degree  of  orientation  corresponded  also  with 
the  degree  of  dementia,  and  also  with  the  degree  of  memory. 
Patient  10,  who  recalled  quite  well  both  recent  and  remote  events, 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      37 

was  fully  oriented  for  time,  place  and  persons,  and  in  general  the 
other  patients  who  exhibited  memory  defects  were  not  oriented. 
One  exception  to  this  general  statement  is  patient  15,  who,  al- 
though he  could  not  recall  much  of  his  own  personal  history,  was 
well  oriented  for  place  and  for  persons  and  also  exhibited  fair 
orientation  for  time.  It  may  also  be  noted  that  patient  14,  whose 
lack  of  cooperation  has  been  mentioned,  appeared  to  know  where 
he  was. 

At  the  time  of  their  admission  to  the  Hospital  the  attention  of 
these  patients  could  be  readily  obtained,  and,  in  two  cases,  10 
and  13,  it  was  noted  that  they  could  attend  to  things  well.  The 
latter  patients  understood  what  was  said  to  them  and  could  carry 
on  a  conversation  coherently  and  relevantly,  and  appeared  to  be 
able  to  attend  to  such  impressions  as  they  received.  Cases  11 
and  15  also  exhibited  a  fair  degree  of  attention  ability,  although 
at  the  same  time  it  was  noted  that  their  memory  was  defective. 
On  the  other  hand,  case  12  was  apparently  unable  to  attend  to 
things  well,  for  he  is  noted  to  have  been  unable  to  attend  to 
what  was  said  to  him  or  to  comprehend  readily,  and  case  14  also 
exhibited  a  similar  difficulty  of  attention.  These  variations,  like 
those  in  the  dementia  precox  group,  are  not  associated  with  the 
special  lesions. 

These  six  cases  of  paresis  do  not  differ  extensively  from  one 
another  in  symptomatology,  although  they  may  be  differentiated 
as  belonging  to  the  simple  dementing  form  (e.g.,  case  14)  or  to 
the  expansive  form  (e.g.,  case  10)  of  the  disease.  Although  the 
symptoms  in  these  cases  are  more  nearly  equal  than  in  the  cases 
of  dementia  precox,  the  differences  are  also  sufficiently  evident  to 
make  possible  a  comparison  with  the  difference  in  the  extent  of 
the  lesions.  It  appears,  however,  that  the  symptomatological  dif- 
ferences are  not  to  be  correlated  with  the  anatomical  differences 
in  the  extent  or  the  severity  of  the  anterior  atrophies.  Those 
patients  who  exhibited  only  frontal  atrophies  were,  apparently, 
as  markedly  demented,  they  showed  about  the  same  degree  of 
emotional  or  affective  change,  and  they  exhibited  lack  of  memory, 
of  orientation,  of  attention,  and  of  comprehension  to  about  the 


>>  s   it    i 


38  SHEPHERD  IVORY  FRANZ 

same  degree  as  those  cases  in  which  the  atrophy  extended  beyond 
the  limits  of  the  frontal  lobes.  On  the  other  hand,  it  appears 
equally  probable  that  with  frontal  or  with  anterior  atrophies  some 
paretic  parents  will  exhibit  a  fair  degree  of  memory  and  others 
an  almost  complete  loss  of  memory,  that  some  will  have  fantastic 
or  persecutory  or  grandiose  delusions  and  others  will  have  none  of 
these.  It  is  apparent,  therefore,  that  with  comparable  lesions 
the  symptoms  may  differ,  and  that  with  lesions  which  do  not 
even  approximately  correspond  the  symptoms  may  be  similar.. 


ARTERIOSCLEROTIC  DEMENTIA,  CLINICAL 
HISTORIES 

Case  1 6,  white  male,  was  admitted  at  the  age  of  63,  and  died 
7  years  and  4  months  later. 

The  diagnosis  on  admission  was  acute  confusional  insanity, 
intoxication  psychosis;  the  duration  was  given  as  three  months 
plus;  he  was  noted  as  having  used  alcohol  only  moderately;  the 
medical  certificate  stated  that  he  burned  papers  on  the  floor 
of  his  room;  frequently  wandered  around  aimlessly  at  night; 
showed  loss  of  memory,  with  all  the  symptoms  of  senility;  had 
fixed  transitory  delusions,  one  of  his  fixed  delusions  being  that 
he  was  "still  in  active  service  in  the  army,  but  at  that  time  on 
furlough";  he  was  disoriented  for  time;  he  made  meaningless 
remarks.  His  family  history  was  negative.  On  admission  he 
was  disoriented  for  time;  appeared  perfectly  satisfied  with  his 
surroundings;  showed  only  a  slight  amount  of  insight;  he  was 
up  and  about  the  ward ;  his  expression  was  placid ;  he  was  poorly 
nourished  but  there  were  no  physical  or  neurological  abnormali- 
ties. His  intellect  and  memory  were  defective;  his  attention 
could  be  obtained  and  held  without  difficulty;  he  was  quiet  and 
orderly;  he  appeared  to  be  much  demented,  and  seldom  spoke 
unless  addressed;  he  remained  seated  in  one  place  in  the  ward 
the  greater  part  of  the  day;  he  comprehended  readily,  and  his 
replies  were  given  promptly  and  were  relevant  and  coherent; 
no  delusions  or  hallucinations  were  elicited.  Later  he  claimed 
that  some  one  put  laudanum  in  his  beer,  and  that  this  had 
doped  him  and  caused  him  to  be  sent  here;  when  asked  if  any 
one  had  put  poison  in  his  food  since  he  was  in  the  Hospital, 
he  said  it  was  not  for  him  to  say,  he  became  indignant,  his  face 
flushed,  and  he  said  he  had  a  right  to  his  beliefs;  a  speech 
defect  was  observed.  For  over  a  year  previous  to  his  death 
he  was  confined  to  bed;  he  became  disturbed  and  excited  if 
he  did  not  get  the  things  he  wanted ;  he  thought  some  one  had 


40  SHEPHERD  IVORY  FRANZ 

Stolen  his  money,  hidden  his  clothes,  and  imposed  upon  him  in 
various  other  ways;  his  memory  grew  more  defective,  and  he 
was  unable  to  give  the  name  of  the  institution ;  he  thought  some 
one  was  sending  electric  currents  through  him,  and  that  these 
caused  contracture  of  his  fingers;  his  feet  and  legs  became  con- 
tracted about  six  months  before  his  death. 

The  autopsy  showed  atrophy  of  the  frontal  convolutions ;  there 
was  left  bronchopneumonia,  and  the  kidneys  showed  a  slight 
degree  of  swelling  and  some  inflammation. 

Case  17,  white  male,  was  admitted  at  the  age  of  65  and 
subsequently  lived  for  a  little  over  a  year. 

His  family  and  personal  history  was  negative;  the  medical 
certificate  stated  that  the  patient  had  been  nervous  and  talked 
at  random  about  large  amounts  of  money  he  thought  he  was 
going  to  get  from  people  in  England;  he  made  all  kinds  of 
absurd  statements ;  he  asked  to  have  his  i eet  and  toes  amputated ; 
he  could  not  carry  on  a  connected  conversation  and  he  attempted 
violence  upon  other  inmates  in  the  Soldiers'  Home  in  which 
he  was.  On  admission  to  the  Hospital  he  was  restless  most 
of  the  time;  he  would  not  sit  for  even  a  few  nxinutes  in  one 
place;  he  appeared  to  be  profoundly  demented;  he  was  disori- 
ented; his  memory  was  markedly  defective,  and  his  talk  was 
disconnected  and  incoherent;  coarse  tremors  of  the  tongue  were 
noted;  the  pupils  reacted  slowly  in  accommodation,  and  the 
superficial  reflexes  could  not  be  elicited;  his  coordination  was 
fair;  physically  he  showed  signs  of  cardiovascular  renal  disease 
and  pulmonary  tuberculosis. 

In  addition  to  these  the  autopsy  showed  marked  shrinkage 
of  the  brain,  especially  in  the  frontal  regions. 

Case  18,  colored  male,  73  years  old  at  the  time  of  admission, 
lived  for  about  i  year  subsequently. 

The  certificate  accompanying  the  patient  stated  that  he  had 
impaired  cerebration,  and  for  the  preceding  six  years  there  had 
been  a  tendency  on  his  part  to  wander  away.    On  his  admission 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      41 

to  the  Hospital  he  was  found  to  be  enfeebled;  he  was  restless; 
the  only  thing  that  could  be  elicited  from  him  by  questioning 
was  his  name;  he  was  disoriented;  he  talked  very  indistinctly; 
he  seemed  to  be  very  much  demented;  he  was  tidy  in  habits; 
spasmodic  laughing  and  crying  and  negativistic  tendencies  were 
noted;  he  showed  perseveration;  his  voluntary  acts  were  appar- 
ently purposeless,  and  his  movements  were  inaccurate;  neuro- 
logically,  there  were  no  atrophies  found;  a  slight  arcus  senilis 
was  present;  there  were  marked  tremors;  his  gait  was  slow  and 
unsteady,  and  his  walk  was  shuffling;  he  was  noted  to  have  some 
ataxia;  although  a  right  homonymous  hemiamopia  was  noted 
in  the  history,  this  was  not  detectable  at  a  later  date  and  may 
have  been  surmised  because  of  special  acts  due  to  his  negativism 
and  his  general  mental  inertia;  sensory  and  motor  aphasia  were 
also  noted;  smell  was  diminished;  there  was  a  diminished  sense 
of  temperature  and  a  hypoalgesia;  he  was  untidy  in  habits  and 
he  could  not  find  his  bed ;  he  took  no  interest  in  his  surroundings, 
and  at  the  time  of  his  death  he  was  in  a  condition  of  extreme 
dementia. 

The  autopsy  revealed  shrinkage  of  the  cerebral  convolutions, 
especially  in  the  frontal  lobes,  pachymeningitis,  slight  arterio- 
sclerosis of  the  basal  vessels,  valvular  heart  disease,  atheromatous 
aorta,  congestion  of  the  kidneys. 

Case  19,  white  male,  was  admitted  at  the  age  of  62  and 
lived  16  years.  At  the  time  of  admission  no  information  was 
received  regarding  him  except  that  the  diagnosis  of  "acute  mania" 
had  been  made. 

In  the  Hospital  he  was  orderly  and  quiet  and  assisted  with 
the  ward  work;  he  was  fond  of  reading;  he  spoke  very  little 
voluntarily,  but  answered  questions  readily;  he  was  untidy  in 
appearance,  and  he  collected  and  filled  his  bed  with  trash;  he 
was  very  childish;  at  times  he  talked  almost  incessantly.  Later 
he  was  noisy  and  restless,  somewhat  destructive  and  untidy,  and 
he  became  hypochondriacal,  and  sometimes  had  to  be  restrained 
but  at  other  times  he  associated  with  the  other  patients  and 
played  games  with  them;  he  comprehended  what  was  said  to 


42  SHEPHERD  IVORY  FRANZ 

him;  he  was  coherent  and  relevant  in  his  conversation,  but  his 
reasoning  and  judgment  were  limited;  his  memory  was  poor 
for  recent  events,  but  he  appeared  to  take  considerable  interest 
in  his  surroundings,  and  was  oriented  in  all  spheres ;  his  station 
was  good  but  his  gait  was  rather  unsteady;  there  was  noted 
a  slight  double  cataract  and  double  arcus  senilis. 

The  autopsy  revealed  internal  hemorrhagic  pachymeningitis, 
shrinkage  of  the  anterior  convolutions  but  no  other  gross  cerebral 
lesions,  sclerosis  of  the  aorta  and  of  the  cerebral  basal 
vessels,  pulmonary  tuberculosis  and  pneumonia,  and  intestinal 
tuberculosis. 

Case  20,  white  male,  age  72  on  admission  and  lived  for  i 
year  and  I/2  month.  He  had  been  gradually  losing  his  mental 
faculties  for  a  year,  and  while  in  another  institution  he  had 
been  unable  to  find  his  bed  and  to  take  care  of  himself ;  he  was 
disoriented  and  confused,  and  had  no  insight. 

There  was  fine  tremor  of  the  tongue;  pupils  were  slightly 
irregular  in  outline;  the  heart  was  somewhat  enlarged;  there 
was  a  coarse  tremor  of  the  right  arm ;  the  tendon  reflexes  could 
not  be  elicited ;  station  and  gait  were  greatly  impaired.  He  was  not 
oriented  for  time,  place,  or  person;  his  memory  for  recent  and 
remote  events  was  very  poor;  emotionally  he  was  apparently 
indifferent;  there  was  no  insight;  no  hallucinations  or  delusions 
were  detected;  the  patient  was  quiet,  feeble,  and  was  agreeable 
and  rather  childish  in  his  reaction;  three  or  four  days  before 
his  death  he  could  not  move  his  left  arm  and  leg;  the  tongue 
was  protuded  slightly  to  the  left ;  there  was  Babinski  phenonema 
on  the  left;  whether  or  not  this  attack  was  accompanied  by  a 
convulsive  seizure  is  unknown. 

The  autopsy  showed  shrinkage  of  the  frontal  lobes;  hem- 
orrhage was  found  in  the  Rolandic  region;  in  the  left  occipital 
lobe  there  was  an  old  softening  affecting  this  part;  the  heart 
valves  were  insufficient,  and  the  heart  enlarged;  and 
parenchymatous  nephritis. 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      43 

Case  21,  colored  male,  65  years  old  at  the  time  of  admission 
and  lived  3!/^  years  subsequently. 

The  medical  certificate  stated  that  the  patient  had  been  normal 
until  a  few  years  previous  to  his  commitment;  he  had  bad  mem- 
ory and  did  not  seem  to  remember  anything ;  he  was  disoriented 
for  time  and  place;  he  was  restless,  he  talked  senselessly;  his 
reasoning  was  bad ;  and  he  appeared  to  be  excited.  The  physical 
examination  showed  bronchitis,  sclerotic  superficial  vessels,  feeble 
heart  sounds,  no  tremors,  coordination  was  good;  he  had  a  poor 
grip;  there  was  a  slight  arcus  senilis  with  some  visual  impair- 
ment ;  no  speech  defect  was  observed.  On  admission  he  appeared 
to  be  senile;  he  was  quiet  and  tractable;  he  showed  some  con- 
fusion and  marked  clouding  of  consciousness;  he  was  disoriented; 
his  attention  could  not  be  held;  his  memory  was  poor;  his 
conversation  was  rambling  and  incoherent,  and  he  usually 
answered  incorrectly;  no  definite  evidence  of  hallucinations  or 
delusions  was  obtained,  but  he  appeared  to  be  suspicious  that 
he  was  to  be  harmed  in  some  manner;  at  one  time,  however,  he 
said  that  colored  people  had  been  after  him  and  almost  scared 
him  to  death,  but  that  white  people  came  to  his  rescue;  and 
later  he  also  spoke  of  his  farm  and  sheep  having  been  stolen, 
etc. ;  at  times  he  was  restless  and  wandered  around  aimlessly, 
talking  in  a  rambling  manner;  he  became  untidy  in  habits;  he 
was  very  restless,  and  asked  that  he  be  permitted  to  go  to  his 
work. 

The  autopsy  revealed  atrophy  of  the  anterior  convolutions, 
sclerosis  of  the  basal  arteries,  dilated  heart,  and  chronic  cystitis. 

Case  22,  white  male,  was  70  years  of  age  on  admission  and 
lived  for  only  i  month  subsequently. 

His  mother  had  been  insane  and  confined  in  a  hospital ;  other- 
wise, his  family  history  was  negative.  The  patient  always  had 
been  a  heavy  drinker  and  occasionally  he  had  a  prolonged  period 
of  intoxication;  he  had  been  treated  for  dipsomania  a  number 
of  times  and  six  months  prior  to  his  entrance  to  the  Hospital, 
following  a  lengthened  drinking  spree,  he  became  quarrelsome 
and  abusive;  he  thought  other  men  were  putting  lice  into  his 


44  SHEPHERD  IVORY  FRANZ 

bed  and  trying  to  injure  his  reputation  in  other  ways;  he  threat- 
ened them;  he  beheved  he  was  in  command  and  ordered  those 
about  him  to  do  things  for  hirn ;  he  heard  voices  of  women  and 
of  his  superior  officers  talking  to  him  and  he  replied  in  a  loud 
boisterous  voice.  Physically  his  muscles  were  of  poor  tone; 
his  coordination  was  fair;  his  station  and  gait  were  unsteady, 
and  his  apparent  delusion  regarding  lice  may  be  explained  by 
the  fact  that  these  vermin  were  actually  found  upon  his  body; 
he  was  neat  and  tidy  in  appearance;  he  was  disoriented;  he  had 
no  insight;  his  general  memory  was  fair;  there  were  auditory 
hallucinations  of  voices,  but  he  would  give  little  information 
about  the  voices,  people,  or  what  was  said  to  him;  he  became 
irascible;  swore  frequently  and  fluently;  he  thought  everything 
in  the  ward  belonged  to  him ;  he  gave  orders  to  others  to  attend 
to  the  horses,  etc. ;  and  he  conversed  with  imaginary  people  out 
of  the  window. 

The  autopsy  showed  that  the  convolutions  were  atrophied 
anteriorly ;  there  were  also  atheroma  of  the  aorta,  cystic  kidneys, 
interstitial  nephritis,  and  cystitis. 

Case  23,  white  male,  was  admitted  at  the  age  of  47  and 
lived  I  year  and  7  months  subsequently. 

At  the  time  of  his  admission  no  medical  certificate  was 
received  and  no  previous  family  history  was  obtained;  at  first 
he  was  diagnosed  as  an  unclassified  psychosis,  but  on  account 
of  the  pathological  findings  this  was  changed  to  arteriosclerotic 
dementia.  On  admission  he  appeared  to  have  no  use  of  his 
legs  from  his  knees  downward;  he  said  he  knew  he  was  going 
to  be  killed  and  burning  was  the  way  to  do  it;  he  imagined 
that  people  were  talking  about  him,  and  he  heard  them  talking 
about  it  at  night ;  he  imagined  he  had  plenty  of  money ;  he  was 
noisy,  untidy,  occasionally  talkative;  he  continually  complained 
about  everything,  and  he  was  very  irritable;  he  was  oriented; 
his  memory  was  only  fair;  at  times  he  was  stupid;  at  one  time 
he  had  a  convulsion  afifecting  the  right  side,  after  which  he 
could  not  talk.  Later  he  had  a  convulsion  principally  on  the 
left  which  also  aflFected  the  right. 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      45 

At  the  autopsy  it  was  found  that  he  had  bronchopneumonia, 
atheroma  of  the  coronary  artery  and  of  the  aorta,  nephritis, 
and  the  convolutions  of  the  anterior  half  of  the  brain  were 

considerably  shrunken. 

* 

Case  24,  white  male,  admitted  to  the  Hospital  at  the  age  of 
55,  and  lived  nearly  18  years  subsequently.  He  had  been  ad- 
mitted to  a  Soldiers'  Home  because  of  a  paralysis  and  epileptic 
seizures.     There  he  attempted  suicide  and  was  violent  at  times. 

On  entrance  to  the  Hospital  he  was  found  to  be  deaf;  he 
was  depressed  and  had  many  morbid  fancies.  Later  he  was  noted 
to  be  feeble,  quiet,  orderly ;  he  did  not  answer  intelligently ;  his 
mind  wandered ;  he  was  indifferent  to  his  surroundings ;  he  was 
completely  disoriented  and  showed  no  insight  into  his  condition ; 
at  times  he  became  very  talkative  and  destructive,  although  most 
frequently  he  was  quiet  and  comfortable;  delusions  of  a  pleas- 
urable nature  were  evident  at  times,  and  later  these  gave  way 
to  delusions  of  persecution  when  he  talked. about  the  property 
and  money  which  had  been  stolen  from  him;  there  was  left 
hemiplegia  with  contractures;  his  gait  was  firm  and  rugged 
for  one  of  his  physical  condition,  but  he  dragged  his  left  leg; 
the  knee  jerks  were  absent. 

The  autopsy  showed  slight  enlargement  of  the  heart,  hypostatic 
congestion  of  the  lungs,  peritonitis,  ulcerative  cholecystitis, 
granular  kidneys,  marked  shrinkage  of  the  brain,  but  no  areas  of 
softening  or  of  hemorrhage  could  be  found  to  account  for  the 
hemiplegia. 

Arteriosclerotic  Dementia,  Discussion 

Only  two  of  these  cases  (16  and  20)  are  strictly  frontal  cases. 
Two  others  (17  and  18)  were  cases  in  which  there  was  a  certain 
degree  of  atrophy  of  the  cerebrum  as  a  whole  in  addition  to 
the  marked  frontal  atrophy.  The  remaining  five  cases  were 
those  in  which  the  atrophy  extended  over  the  whole  anterior 
portions  of  the  cerebrum.  Case  22  was  noted  to  be  an  alcoholic 
case,  but  the  relation  of  alcoholism  to  the  mental  disorder  is 
not  clear,  and  the  facts  which  have  been  recorded  in  the  history 


46  SHEPHERD  IVORY  FRANZ 

do  not  give  any  indication  that  alcohol  played  any  great  part 
in  the  production  of  the  symptoms  during  his  Hospital  resi- 
dence. We  may  believe,  however,  that  it  was  a  contributing 
factor.  Case  24  appears  at  first  sight  from  the  history  to  be  a 
case  complicated  with  epilepsy,  but  no  epileptiform  convulsions 
occurred  during  the  period  of  his  Hospital  residence,  and  it 
seems  more  likely  that  the  convulsions  were  of  a  character  which 
later  resulted  in  the  left  hemiplegia,  in  other  words,  that  they 
were  seizures  similar  to  an  apoplexy.  Before  death  all  of  these 
patients  exhibited  plain  evidence  of  dementia.  They  were  en- 
feebled, childish,  indifferent,  confused,  were  not  afifected  by 
their  surroundings  to  any  extnet,  and  most  often  exhibited  no 
insight  into  their  mental  condition,  etc.  The  two  cases  which 
showed  most  evidence  of  mental  enfeeblement  (cases  17  and  18) 
were  those  in  which  some  general  atrophy  was  found  to  ac- 
company the  intensive  frontal  atrophies,  and  it  is  possible  that 
the  great  degree  of  dementia  in  these  cases  is  to  be  correlated 
with  the  extension  of  the  atrophy  to  the  posterior  regions  of  the 
cerebrum,  although  the  atrophy  in  the  latter  areas  was  not  of 
great  degree.  The  other  seven  cases  did  not  differ  to  a  great 
extent  in  the  apparent  degree  of  dementia  which  was  present 
immediately  preceding  death,  and  in  this  respect  there  can  be  no 
great  degree  of  correlation  between  the  extent  of  the  atrophy 
and  the  degree  of  the  dementia. 

The  physical  enfeeblement  probably  kept  most  of  these  patients 
less  active  than  would  have  been  normal  for  them,  and  the  two 
patients  who  exhibited  effects  of  paralysis,  cases  16  and  24,  were 
especially  orderly  and  quiet  most  of  the  time.  The  physical 
enfeeblement  did  not,  however,  prevent  these  patients  from  be- 
coming disturbed,  noisy,  restless  and  at  times  excited,  and  these 
states  alternated  with  states  of  quiescence  and  even  confusion,. 
the  only  exception  being  that  case  20  (with  frontal  atrophy) 
was  uniformly  apparently  indifferent,  inactive  and  agreeable. 
Lesions  to  account  for  the  paralytic  phenomena  were  not  dis- 
covered, and  it  may  be  that  part  of  the  contractures  in  these 
patients  were  due  to  disuse  and  not  to  special  paralysis.  In 
other  respects  every  one  of  these  patients   showed   variations 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      47 

from  the  normal  motor  ability,  both  in  the  presence  of  tremors 
and  in  their  inaccurate,  slow,  and  feeble  voluntary  movements. 
Patient  i8,  whose  brain  showed  some  general  atrophy  in  addition 
to  the  marked  atrophy  in  tlje  frontal  regions,  also  exhibited 
negativistic  tendencies,  and  at  other  times  he  appeared  to  be 
purposelessly  active.  This  patient,  it  will  be  noted,  also  showed 
other  symptoms  like  those  of  the  dementia  precox  group  in  that 
he  was  noted  to  laugh  and  to  cry  spasmodically  and  without 
apparent  reason  and  to  show  perseveration.  Both  the  similarities 
and  the  variations  in  these  motor  symptoms  in  these  patients  do 
not  appear  to  be  directly  correlated  with  the  distribution  of  the 
atrophies,  for  the  unsteadiness  and  the  tremors  and  the  rest- 
lessness were  found  equally  in  those  with  frontal  and  in  those 
with  the  more  extensive  atrophies. 

The  speech  disturbances  were  not  as  pronounced  as  in  the 
cases  of  general  paralysis  of  the  insane.  At  least  four  of  these 
cases  could  talk  readily,  and  also  coherently  and  relevantly,  and 
there  was  no  difificulty  in  carrying  on  a  conversation  with  them, 
if  one  did  not  approach  their  delusions  or  in  the  conversation 
make  too  much  of  a  demand  to  strain  their  memory.  There 
was  in  general  none  of  the  speech  defects  which  are  so  com- 
monly found  in  paretics,  and  when  the  patients  would  and  could 
talk,  their  words  were  usually  well-pronounced.  Defective  speech 
was,  however,  noted  in  some  of  them;  patient  i6  was  observed 
to  have  a  slight  speech  defect;  patient  i8  was  also  recorded 
at  one  time  to  have  both  sensory  and  motor  aphasia,  but  the 
diagnosis  of  this  condition  is  a  very  doubtful  one,  and  should 
be  accepted,  if  at  all,  with  caution,  for  at  that  time  the  patient 
was  in  a  very  negativistic  mood;  patient  23  also  showed  a  motor 
aphasia  after  a  convulsive  attack.  Assuming  the  accuracy  of 
the  facts  just  mentioned,  we  may  believe  that  these  conditions 
were  due  to  local  cerebral  injuries  that  were,  however,  not 
discovered  at  autopsy,  and  which  may  have  been  temporary 
or  functional.  Considering  only  the  speech  ability  anterior  to 
these  accidents,  we  find  that,  with  the  exception  of  case  23, 
the  speech  of  all  the  patients  was  similar;  at  times  it  was  almost 
incessant,  at  other  times  they  conversed  voluntarily  very  little 


^  SHEPHERD  IVORY  FRANZ 

but  would  answer  questions,  and  at  other  times  it  was  difficult 
to  get  any  information  from  them.  In  other  respects  also  their 
talk  was  similar;  two  patients  with  frontal  and  two  patients 
with  anterior  atrophies  talked  at  random,  or  incoherently,  two 
other  patients  with  frontal  and  two  patients  with  anterior 
atrophies  talked  relevantly  and  could  carry  on  conversations  on 
minor  matters.  In  these  respects,  therefore,  we  find  with  similar 
atrophies  quite  dissimilar  characters  of  symptoms,  and  with 
dissimilar  atrophies  quite  similar  symptoms. 

The  affective  conditions  in  these  patients  differed  widely.  Of 
the  patients  with  frontal  lesions  three  varied  from  an  indifference 
to  a  general  satisfied  condition,  but  the  fourth  patient  exhibited 
from  time  to  time  spasmodic  laughing  and  crying,  but  whether 
this  alternation  was  accompanied  by  the  appropriate  emotional 
states  is  not  sure.  This  reaction  has  previously  been  compared 
with  those  of  dementia  precox  patients,  and  in  addition  it  may 
be  said  that  it  also  resembles  to  a  certain  degree  the  similar 
symptom  associated  with  lesions  of  the  optic  thalamus,  especially 
in  view  of  the  association  of  hypoesthesia  for  temperature  and 
pain.  One  of  these  patients  (case  i6),  in  speaking  of  his  de- 
lusions of  persecution,  did  not  appear  to  react  with  appropriate 
emotional  tone  to  them.  The  other  five  patients,  those  with 
anterior  lesions,  were  depressed,  suspicious,  irascible,  and  quarrel- 
some, with  more  normal  or  more  contented,  or  indifferent, 
intervening  periods.  Four  of  the  latter  group  (patients  21,  22, 
23,  and  24)  had  corresponding  delusions,  and  their  affective 
states  were  associated  with  and  corresponded  with  these  other 
mental  derangements.  Patient  19,  on  the  other  hand,  appeared 
hypochondriacal  without  apparent  reason,  for  if  he  had  delu- 
sions, they  were  not  made  evident  (see  below),  and  no  hallucina- 
tions were  discovered.  Whether  or  not  the  greater  frequency 
of  particular  types  of  emotional  reactions  and  of  special  feelings 
is  to  be  definitely  correlated  with  the  more  extensive  lesions  can 
not  be  determined.  That  the  general  atrophy  in  cases  17  and 
18,  which  it  will  be  remembered  was  associated  with  a  more 
marked  degree  of  frontal  atrophy,  did  not  produce  similar 
affective  states  is  an  indication  that  the  special  emotional  con- 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      49 

ditions,  which  superficially  appear  to  be  definitely  associated 
with  the  anterior  lesions,  are  better  interpreted  as  chance  oc- 
currences, and  that  in  a  more  extensive  series  they  would  probably 
not  be  found  in  as  great  proportion.  This  conclusion  also  appears 
more  likely  in  view  of  the  results  which  have  been  found  in  the 
other  diseases  which  have  been  studied. 

Only  one-third  of  these  cases  gave  evidence  of  hallucinations. 
These  were  cases  i6,  22  and  23.  Apparently  case  16  had 
paresthesias  in  the  fingers,  for  he  complained  that  electric  cur- 
rents were  sent  through  him  so  that  they  caused  contractures 
of  these  parts.  Regarding  the  other  delusions  of  which  he  com- 
plained, viz.,  that  he  had  been  doped  and  that  laudanum  had 
been  put  into  his  beer,  it  is  more  difficult  to  judge  whether 
these  were  purely  ideational  delusions  or  delusions  due  to 
paresthesias.  The  auditory  hallucinations  of  patients  22  and  23 
were  very  evident,  but  when  patient  22  conversed  with  imaginary 
people  outside  of  his  window,  it  was  not  certain  that  the  hallucina- 
tions were  entirely  auditory.  The  peculiar  requests  of  patient 
17  that  his  feet  be  amputated  might  be  due  to  hallucinations, 
but  this  was  not  determined.  Those  patients  who  had  sensory 
defects  (patient  24  with  deafness,  patient  21  with  visual  defect, 
and  patient  18  with  hypoesthesia  for  smell,  temperature  and  pain) 
did  not  apparently  have  hallucinations  either  in  these  fields  or 
in  others,  nor  did  patient  20  in  whose  brain  a  small  softening 
was  discovered  in  the  left  occipital  lobe.  These  facts  do  not 
indicate  any  definite  relation  between  the  mental  conditions  and 
the  extent  or  degree  of  the  cerebral  atrophy. 

There  appears  to  be  no  more  direct  connection  between  the 
presence  or  the  character  of  delusions  and  the  atrophies  of  the 
anterior  portions  of  the  cerebrum.  Patients  18  and  20  did  not 
have  delusions  which  were  detected,  and  one  of  these  (case  18) 
will  be  recalled  as  having  had  general  as  well  as  the  well-marked 
frontal  atrophy,  the  other  being  a  simple  frontal  case.  The 
other  two  patients  with  frontal  atrophies  did  have  delusions, 
some  of  the  delusions  in  both  being  allied  to  hallucinatory 
phenomena,  although  a  conclusion  regarding  this  relation  can 
not  be  stated  with  definiteness.    The  delusion  of  patient  16  that 


so  SHEPHERD  IVORY  FRANZ 

he  was  still  in  active  army  service  was  probably  a  filling-out  due  to 
memory  defects,  but  those  regarding  the  loss  of  money,  the  ac- 
tion of  electric  currents  and  the  presence  of  poison  in  his  food 
are  probably  not  due  to  this  failure  of  memory,  nor  do  the 
delusions  of  patient  17  regarding  the  money  which  he  expected 
from  England  appear  to  be  restrospective  interpretations. 
It  can  not  be  said  with  certainty  that  patient  19  did  or  did  not 
have  delusions;  the  fact  that  he  collected  and  attempted  to  fill 
his  bed  with  trash  indicates  that  he  believed  this  to  have  some 
value  or  to  have  some  relation  to  himself,  but  information  on 
this  point  is  totally  lacking.  The  other  four  patients,  all  with 
anterior  lesions,  had  delusions  of  persecution  which  with  the 
exception  of  those  of  patient  21  alternated  with  mild  delusions 
of  grandeur. 

All  of  these  patients  showed  defective  memory,  and  although 
it  is  almost  impossible  to  determine  the  degree  of  the  defect 
in  the  individual  cases,  the  general  reactions  of  patients  16,  17,  20 
and  21  would  lead  to  the  conclusion  that  they  were  more  abnormal 
in  this  respect  than  the  other  four  cases.  Four  of  these  patients, 
it  will  be  noted,  are  cases  of  frontal  lesions,  and  the  memory 
defects  seem  to  be  correlated  with  the  degree  of  dementia,  since 
it  has  already  been  mentioned  that  two  of  these  (cases  17  and 
18)  were  profoundly  demented.  The  other  two  frontal  cases, 
patients  16  and  20,  were  confused  and  bewildered  and  in  their 
cases  the  memory  defects  may  be  either  evidence  of  the  con- 
fusion or  the  result  or  the  concomitant  of  these  conditions- 

In  marked  contrast  to  the  character  of  the  memory  is  the 
orientation  of  the  individual  cases.  Patients  17,  18,  20,  22,  and 
24  were  completely  disoriented;  patient  16  was  disoriented  for 
time;  and  patient  21  was  disoriented  for  time  and  places.  The 
partial  orientation  of  patients  16  and  21  is  the  more  remarkable 
in  view  of  their  poor  memory,  and  the  good  orientation  of 
patients  19  and  23  is  also  to  be  contrasted  with  the  degree  of 
memory  loss.  The  latter  two  cases,  it  will  be  recalled,  are  cases 
of  anterior  lesions,  and  this  fact  indicates  that  even  with  such 
extensive  changes  orientation  for  time  and  space  may  be  retained. 

Not  much  more  can  be  said  regarding  the  other  mental  pro- 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      51 

cesses  directly,  although  indirect  information  is  obtainable  in 
the  case  histories  regarding  the  patients'  ability  to  attend  to 
impressions.  In  general,  in  these  cases  of  arteriosclerotic  de- 
mentia there  remains  considerable  ability  to  attend  to  impressions, 
as  has  also  been  shown  experimentally,  and  this  ability  appears 
to  be  independent  of  the  memory  disorder.  Even  though  the 
patient  was  apparently  very  much  demented  or  even  confused, 
his  attention  could  usually  be  obtained  without  difficulty,  and 
this  was  noted  especially  for  cases  16,  19,  20,  22,  and  24.  At 
times  patient  23  appeared  stupid,  i.e.,  his  attention  could  not  be 
obtained,  and  although  the  attention  of  patient  21  could  be 
obtained  it  could  not  be  held.  Whether  or  not  we  shall  interpret 
the  perseveration  of  patient  18  as  "good"  or  "poor"  attention 
can  not  be  definitely  settled ;  there  is  sufficient  ground  for  either 
conclusion.  The  fact  that  with  either  frontal  or  anterior 
atrophies  there  may  be  good  ability  to  attend  is  an  argument 
against  the  supposition  of  an  "attention  function"  for  the  frontal 
lobes,  and  the  fact  that  the  ease  or  difficulty  of  attracting  the 
attention  did  not  differ  in  accordance  with  the  extent  of  the 
lesions  which  are  here  considered  is  evidence  that  direct  correla- 
tion does  not  exist. 

The  variations  in  the  mental  processes  which  have  here  been 
considered  permit  the  conclusion  that  neither  the  extent  nor  the 
severity  of  the  atrophy  of  the  anterior  regions  of  the  brain 
in  arteriosclerotic  dementia  is  directly  correlated  with  the  mental 
symptoms,  and  they  also  show  that  with  similar  atrophies  dis- 
similar symptoms  may  be  frequently  encountered  in  different 
patients. 


SENILE  DEMENTIA,  CLINICAL  HISTORIES 

Case  25,  white  male,  aged  63  on  admission,  had  been  admitted 
in  an  obviously  insane  condition  to  a  Soldiers'  Home  43^  months 
previously,  and  lived  13  months  subsequent  to  his  admission 
to  the  Hospital.  In  the  Soldiers'  Home  he  was  very  restless, 
constantly  wandered  about,  exhibited  a  defective  memory,  was 
careless  of  his  personal  appearance,  and  imagined  that  strangers 
were  relatives  who  had  been  dead  for  years.  Physically  there 
were  incontinence  of  urine,  chronic  cystitis,  and  marked  tachy- 
cardia. No  family  or  previous  personal  history  could  be  obtained. 
Neurologically,  there  was  tremor  of  the  extended  hands  and 
protruded  tongue,  most  of  the  tendon  reflexes  were  exag- 
gerated, coordination  and  station  were  good,  the  larger  vol- 
untary movements  were  fairly  accurate  and  exact,  but  his  hand- 
writing was  very  shaky.  He  smiled  and  laughed  spasmodically 
and  without  apparent  reason,  and  without  any  apparent 
emotional  accompaniment;  he  responded  very  poorly  to  the 
routine  mental  examination,  forgot  the  questions  which  were 
asked,  and  showed  little  memory  for  his  past  life  and  what 
information  he  gave  was  apparently  incomplete  and  inaccurate; 
he  could  not  find  his  bed;  he  appeared  to  have  no  intelligent 
understanding ;  he  had  no  insight  into  his  condition ;  no  hallucina- 
tions or  delusions  could  be  elicited;  he  was  disoriented  in  all 
fields,  and  addressed  patients  and  others  by  names  not  theirs, 
apparently  thinking  them  friends  or  relations;  he  was  so  untidy 
that  he  had  to  be  cared  for  in  bed.  Death  was  due  to  hypostatic 
pneumonia.  In  addition,  the  autopsy  showed;  chronic  cystitis, 
nephritis,  hemorrhagic  enteritis,  heart  valves  atheromatous,  and 
circumscribed  atrophy  of  the  frontal  lobes,  but  no  other  cerebral 
lesions.  The  clinical  diagnosis  was  arteriosclerotic  dementia, 
but  the  miscroscopical  examination  of  the  brain  showed  senile 
changes  and  did  not  confirm  the  clinical  diagnosis,  and  the 
case  is,  therefore,  included  in  this  section. 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      53 

Case  26,  white  male,  had  been  noted  as  insane  for  10  months 
previous  to  his  admission  at  the  age  of  67;  Hospital  residence 
was  8  months.  The  signs  of  insanity  noted  on  the  medical 
certificate  were :  the  patient  wandered  away  from  the  ward,  tore 
his  clothing,  he  showed  mental  confusion,  impairment  of  mem- 
ory, occasional  maniacal  manifestations,  incoherent  talk,  and  was 
sleepless.  The  account  he  gave  of  his  family  and  past  life  was 
incomplete  but  negative.  Physically  he  had  hypertrophied  heart, 
superficial  arteriosclerosis,  slight  arcus  senilis,  his  hearing  was 
impaired,  the  tendon  reflexes  were  mostly  exaggerated,  and  there 
was  a  tremor  of  extended  fingers.  He  was  kept  in  bed  as 
much  as  possible,  and  at  first  was  quiet  and  orderly,  cooperating 
well.  The  mental  examination  showed  a  total  lack  of  orienta- 
tion, no  insight  except  that  at  one  time  the  patient  said  that 
if  the  questions  had  been  asked  a  month  previous  he  would  have 
been  able  to  answer  them ;  his  memory  was  very  poor  for  recent 
and  remote  events;  the  only  evidence  of  a  delusion  was  his 
statement  that  he  had  been  robbed  of  thousands  of  dollars;  his 
talk  was  disconnected,  but  his  speech  was  good.  Later  he 
became  restless,  fumbled  with  the  bed  clothing,  was  noisy,  sang 
loudly,  laughed  and  talked  to  himself,  usually  calling  to  horses, 
as  if  he  were  taking  care  of  or  driving  them,  and  advising  those 
around  him  to  get  out  of  the  way  or  the  horses  would  run  over 
them;  he  pulled  the  bed  clothing  and  his  remarks  were  ap- 
parently due  to  ideas  that  he  was  driving ;  he  took  off  his  clothes 
and  went  about  his  room  naked;  apparently  did  not  know  how 
to  put  them  on,  for  he  was  found  putting  his  shirt  over  his 
legs.  The  autopsy  showed  shrinkage  of  the  convolutions  of 
the  frontal  lobes,  but  no  other  gross  cerebral  lesions ;  heart  valves 
atheromatous,  hypostatic  congestion  of  the  lungs,  congestion 
of  the  stomach,  intestines,  liver,  spleen  and  bladder,  and  slight 
fibrosis  of  the  kidneys. 

Case  27,  white  male,  as  an  inmate  of  a  Soldiers'  Home  was 
considered  to  be  senile  for  nearly  two  years  previous  to  his 
entrance  to  this  Hospital  at  the  age  of  87,  where  he  lived  2 
years  and  5  months. 


54  SHEPHERD  IVORY  FRANZ 

The  medical  certificate  stated  that  he  was  careless  of  his 
personal  appearance,  was  childish,  and,  unless  confined,  wandered 
away  and  became  lost.  Physically  he  was  very  active  for  one 
of  his  age,  and  was  in  good  general  health.  He  showed,  how- 
ever, a  beginning  cataract  in  both  eyes  and  was  very  deaf; 
there  was  sclerosis  of  the  superficial  arteries,  the  muscles  were 
small  (atrophied)  and  their  force  was  slight,  but  movements 
were  accurate  and  quick ;  there  was  a  fine  tremor  of  the  extended 
hands;  gait  was  normal  and  coordination  was  good.  He  was 
quite  cheerful;  he  wandered  about  the  wards  in  an  aimless 
manner;  he  slept  wherever  he  happened  to  sit  down;  he  was 
untidy  in  habits;  he  lost  his  way  on  the  ward;  he  was  com- 
pletely disoriented;  he  seldom  spoke  voluntarily,  but  answered 
cheerfully;  he  was  inclined  to  be  argumentative,  especially  re- 
garding religious  topics ;  he  showed  marked  humor ;  occasionally 
he  was  excited  and  disagreeable  and  fought  with  other  patients; 
he  persisted  in  keeping  his  clothes  on  night  and  day ;  his  memory 
was  impaired,  but  he  talked  intelligently  about  historical  events 
of  which  he  had  read;  he  spoke  of  $i,ooo  which  he  believed  he 
had  and  which  he  wished  to  get  so  that  he  could  go  to  his  friends ; 
this  was  the  only  near-delusion  which  was  elicited.  Death  was 
due  to  cardiovascular  and  renal  diseases ;  the  autopsy  also  showed 
atrophy  of  the  frontal  convolutions,  arteries  sclerosed,  emphy- 
sematous lungs  and  consolidation  of  the  right  lung,  nutmeg 
liver. 

Case  28,  white  male,  was  noted  to  have  mental  enfeeblement 
454  months  previous  to  his  admission  at  the  age  of  71 ;  he  lived 
10^  months. 

Neither  family  nor  previous  personal  histories  could  be  ob- 
tained on  account  of  the  patient's  condition.  There  were  no 
previous  attacks  known,  and  the  first  signs  of  mental  enfeeble- 
ment became  evident  only  a  few  months  before  his  entrance  to 
the  Hospital.  Alcoholism  was  given  on  the  medical  certificate 
as  a  probable  cause  of  his  condition,  which  was  noted  to  be  a 
"confusion."  He  believed  himself  to  be  on  board  a  ship,  per- 
secuted,  without  his  rights  and  often  asked  when  he  was  to 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      55 

be  murdered ;  he  also  had  hallucinations  and  threatened  to  com- 
mit suicide ;  he  was  quiet  and  unassuming.  Neurologically,  hear- 
ing was  much  impaired,  a  slight  degree  of  arcus  senilis  was 
present,  and  the  right  pupil  was  smaller  than  the  left;  there 
were  slight  tremors  of  the  fingers;  skin  sensations  were  some- 
what impaired;  all  tendon  reflexes  were  very  much  diminished 
with  the  exception  of  the  biceps.  He  was  disoriented  for  time, 
place,  and  persons;  his  memory  for  even  the  general  events 
of  his  life  was  very  uncertain;  his  remarks  were  almost  un- 
intelligible; but  he  appeared  to  have  some  insight,  i.e.,  he  said 
he  thought  his  mind  was  affected  in  some  way;  he  took  no 
account  of  the  time  or  condition  of  things,  he  complained  of 
the  weather  being  snowy  and  cold  when  it  was  bright  and 
warm,  and  he  inquired  why  he  was  without  shoes  and  clothes 
with  the  snow  up  to  his  knees ;  he  denied  having  hallucinations ; 
he  also  said  he  did  not  mind  the  snakes,  but  he  was  afraid  of 
the  big  alligators  lying  flat  with  their  eyes  down;  looking  up 
at  the  ceiling  he  talked  at  imaginary  people,  and  his  remarks 
could  not  be  understood,  except  that  he  swore  and  became  very 
excited  and  sang  and  shouted.  At  one  time  he  was  found  to 
have  a  twitching  of  the  eyelids,  and  later  the  left  and  then  the 
right  arm  were  noted  to  be  twitching  (convulsion?)  ;  after  this 
the  Babinski  phenomenon  was  present  on  the  left,  and  he  moved 
the  left  hand  more  than  the  right.  The  autopsy  showed  that  the 
right  hemisphere  was  shorter  than  the  left,  and  there  was  slight 
shrinkage  in  the  left  frontal  region;  no  other  gross  cerebral 
lesions  were  observed;  the  heart  was  dilated,  with  few  athero- 
matous patches  on  the  valve  leaflets  and  on  the  aorta ;  pulmonary 
tuberculosis  and  hypostatic  congestion;  nephritis.  The  mico- 
scopical  examination  revealed  senile  changes,  although  the 
primary  clinical  diagnosis  had  been  arteriosclerotic  dementia, 
and  the  case  is  therefore  classed  with  the  senile. 

Case  29,  colored  male,  .his  age  on  admission  was  69,  the 
duration  of  the  mental  disease  was  not  given,  but  the  patient 
had  been  in  this  Hospital  for  more  than  four  years  with  a  mental 
disturbance,  the  nature  of  which  is  not  clear  on  account  of  lack 


56  SHEPHERD  IVORY  FRANZ 

of  clinical  data,  13  years  previously.     He  lived  only  2  months 
subsequent  to  his  second  admission. 

No  family  or  personal  history  of  value  could  be  obtained, 
although  his  previous  residence  in  the  Hospital  is  known.  The 
medical  certificate  stated  that  he  exhibited  delusions  of  wealth, 
was  slovenly  in  his  appearance,  sang  and  danced  for  hours, 
but  at  times  was  irritable  and  quarrelled  with  others,  and  was 
unable  to  repeat  test  phrases.  Syphilis  was  given  as  a  probable 
cause  of  his  condition,  but  a  subsequent  Wassermann  test  was 
negative.  When  received  he  complied  with  all  requests  willingly ; 
he  was  extremely  talkative,  spoke  well  and  intelligently;  told 
how  extensively  he  had  traveled  and  recalled  every  place  and 
event  of  importance,  and  his  memory  seemed  to  be  accurate 
and  exact ;  he  spoke  a  few  foreign  phrases  and  thought  he  could 
talk  several  languages;  he  was  bright  and  alert,  was  ready  to 
talk  when  spoken  to  and  ceased  when  requested  and  this  with- 
out apparent  offense;  he  was  restless  and  wished  to  be  doing 
something  all  the  time;  he  denied  having  hallucinations,  and 
his  ideas  of  wealth  were  not  out  of  proportion  to  his  station, 
although  previous  to  his  admission  he  had  pecuHar  ideas  regard- 
ing some  financial  dealings  with  others;  he  jumped  from  one 
topic  to  another  in  his  conversation;  he  was  well  oriented  for 
place  and  persons,  but  not  well  for  time;  he  appeared  to  have 
some  insight  into  his  condition  for  he  said  he  was  a  "bit  excited" 
on  his  admission  and  that  his  memory  was  not  good.  He  said 
he  had  fallen  from  the  seventh-story  window  thirty- four  years  pre- 
vious to  his  admission  and  suflfered  from  "concussion,"  and  had 
been  bothered  with  this  more  or  less  ever  since.  His  feet  were 
swollen  and  the  skin  over  them  was  glazed,  there  was  marked 
dyspnoea,  radical  arteriosclerosis,  double  arcus  senilis,  great 
emaciation,  pulmonary  tuberculosis  .  The  autopsy  showed  slight 
frontal  shrinkage,  but  no  other  cerebral  lesions,  valvular  heart 
disease,  atheromatous  aorta,  tubercular  lungs,  hypostatic  pneu- 
monia, nephritis.  The  miscroscopical  examination  showed 
marked  senile  changes  in  the  cerebrum,  especially  in  the  frontal 
lobes  although  the  clinical  diagnosis  was  arteriosclerotic  dementia 
(maniacal  excitement). 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      57 

Case  30,  white  male,  was  65  at  the  time  of  admission  and  had 
exhibited  mental  disturbances  for  a  year  previous;  he  lived  13 
years  and  2^  months. 

The  medical  certificate  stated  that  he  was  admitted  to  a 
Soldiers'  Home  for  various  disabilities,  including  nervous  pros- 
tration, at  the  age  of  54,  and  he  was  placed  in  the  insane  part 
of  the  Home  a  few  months  previous  to  his  admission  to  the 
Hospital,  on  account  of  "delusional  insanity."  It  was  noted  that 
he  was  quiet  and  depressed;  his  memory  was  imperfect  and  his 
perceptions  were  impaired.  On  admission  he  appeared  deeply 
depressed,  he  was  quiet,  and  apparently  he  took  no  interest  in 
his  surroundings;  evidences  of  delusions  or  of  hallucinations 
were  not  found,  but  he  constantly  asked  questions  about  words 
which  he  found  in  the  books  and  papers  he  read,  and  figured 
a  great  deal  on  paper  about  them.  At  times  he  was  cross  and 
disagreeable  to  other  patients  and  fought  them,  and  was  very 
noisy  in  the  halls  and  had  to  be  secluded.  He  appeared  to  have 
peculiar  ideas  about  politics,  taxation,  the  coinage  of  money  and 
the  money  question,  but  it  was  difficult  to  understand  what  he 
meant ;  he  drew  maps  of  model  towns  and  sent  them  to  different 
people  to  have  them  adopted;  he  talked  freely;  he  was  tidy 
and  cleanly.  Later  he  took  no  interest  in  his  surroundings  and 
the  peculiar  ideas  noted  above  became  exaggerated  and  further 
elaborated;  he  also  thought  that  the  patients  carried  electricity 
around  with  them  and  shot  it  into  him  so  that  he  was  prevented 
from  urinating,  or  that  they  hypnotized  him  and  played  witch- 
craft upon  him;  he  was  described  at  different  times  as  being 
"completely  disoriented"  and  "completely  oriented,"  and  as  hav- 
ing a  "good  memory"  and  a  "poor  memory" ;  he  stated  that  at 
night  when  he  was  alone  and  in  bed  he  used  to  hear  the  voices 
of  his  enemies  speaking  on  political  matters;  he  wrote  inco- 
herently and  almost  incessantly.  His  gait  was  slow,  there  were 
no  paralyses,  the  radial  arteries  were  sclerosed,  general  tremors 
were  present.  Death  was  due  to  chronic  bronchitis.  The  autopsy 
also  showed :  atrophy  of  the  anterior  cerebral  lobes ;  atheromatous 
aortic  valves,  consolidation  of  the  right  lower  lung;  chronic 
cholecystitis;  chronic  inflammation  of  the  liver,  spleen,  kidneys 


58  SHEPHERD  IVORY  FRANZ 

and  bladder.  Three  clinical  diagnoses  were  made  at  different 
times:  (i)  undifferentiated  psychosis  (dementia);  (2)  paranoid 
state  associated  with  arteriosclerosis;  and  (3)  senile  depression. 

Case  31,  white  female;  yy  years  old  at  the  time  of  admission; 
she  lived  8  years  and  3  months  subsequently;  the  duration 
of  the  mental  disease  at  the  time  of  admission  was  not  learned. 

No  family  or  previous  personal  history,  and  no  physical,  in- 
cluding neurological,  examination  accompany  the  records,  al- 
though on  admission  it  was  noted  that  her  health  and  condition 
were  good  for  one  of  her  age.  She  was  much  confused  and 
wandered  around  the  ward  in  an  aimless  manner;  she  was  free 
from  delusions  and  hallucinations;  she  was  forgetful  and  easily 
irritated,  and  childish  and  dependent  in  manner;  she  was  tidy 
in  habits.  A  year  after  her  admission  she  had  an  epileptiform 
convulsion,  which  left  her  very  much  confused  and  reduced 
mentally  but  did  not  result  in  any  paralysis.  Epileptiform  con- 
vulsions were  present  at  irregular  intervals,  and  previous  and 
subsequent  to  these  she  became  confused.  Three  years  after 
her  admission  to  the  Hospital  she  was  noted  to  have  many 
delusions,  especially  those  of  great  wealth,  that  the  attending 
physician  was  her  son,  that  she  was  going  to  will  him  a  great 
deal  of  property;  she  often  said  she  had  just  been  visited  by 
her  relatives;  she  thought  at  times  she  was  Queen  Victoria, 
and  at  other  times  that  the  Queen  was  her  best  friend.  She 
was  noted  to  be  picking  imaginary  objects  from  the  floor  and 
said  she  was  gathering  money  there.  She  became  hypochondria- 
cal; her  memory  was  defective;  she  lacked  insight;  there  was 
poverty  of  ideas;  she  was  disoriented;  and  her  reasoning  and 
judgment  were  impaired.  For  fifteen  months  before  death  she 
remained  in  bed  helpless,  totally  indifferent  to  her  surroundings ; 
she  never  initiated  conversation,  and  answered  only  in  mono- 
syllables. The  autopsy  showed  that  the  convolutions  of  the 
anterior  lobes  were  markedly  shrunken;  in  addition  there  were 
sclerosis  of  the  aorta,  mitral  and  aortic  valvular  lesions,  purulent 
bronchitis,  interstitial  nephritis  and  chronic  cystitis. 


SYMPTOM ATOLOGICAL  DIFFERENCES  IN  THE  INSANE      59 

Case  32,  white  male,  admitted  at  the  age  of  74.  The  duration 
of  his  mental  disturbance  previous  to  entrance  to  the  Hospital 
was  not  recorded.     He  died  in  6  months. 

This  patient  was  admitted  to  a  Soldiers'  Home  where  he 
was  found  to  have  emphysema,  spinal  curvature  and  an  old 
fracture  of  the  ribs  on  the  left  side.  While  in  that  institution 
he  had  a  slight  fever  and  delirium  which  were  thought  to  be 
due  to  gastritis,  and  following  this  he  was  noted  to  show  evi- 
dence of  dementia.  He  talked  incoherently ;  he  wandered  around 
the  ward  and  tried  to  get  out;  he  was  unable  to  find  his  bed, 
and  constantly  disturbed  other  patients  by  getting  into  their 
beds;  he  had  "no  conception  of  anything."  Physically,  he  was 
poorly  nourished,  the  mitral  and  aortic  valves  of  the  heart  were 
slightly  involved,  there  was  sclerosis  of  the  superficial  vessels, 
there  was  bilateral  arcus  senilis;  the  pupils  were  unequal  and 
irregular,  the  right  gave  the  Argyll-Robertson  reaction;  there 
was  tremor  of  the  fingers;  the  tendon  reflexes  were  not  elicited; 
the  Wassermann  reaction  with  the  blood  serum  was  negative. 
He  appeared  to  have  no  insight  into  his  condition,  but  at  one 
time  he  remarked  there  were  things  in  his  mind  he  knew  were 
"not  right";  emotionally  he  was  indifferent;  he  was  disoriented 
for  time,  place  and  persons;  his  memory  was  greatly  impaired; 
he  was  unable  to  find  his  seat  in  the  dining  room  or  his  bed 
at  night;  he  was  up  and  dressed  and  was  fairly  tidy;  as  a  rule 
he  was  quiet  and  orderly,  but  later  became  very  much  confused, 
restless  and  untidy  in  habits.  A  right  lobar  pneumonia  developed, 
from  which  the  patient  died;  at  the  autopsy  there  were  also 
found :  cerebral  convolutions  atrophied  anteriorly ;  calcification 
of  the  aortic  and  mitral  valves;  atheromatous  arch  of  the  aorta; 
tubercular  scars  in  the  left  lung;  liver  and  spleen  somewhat 
cirrhotic;  cortices  of  kidneys  markedly  thinned. 

Case  33,  white  male,  admitted  at  the  age  of  79,  had  been  ob- 
served for  over  a  year  to  show  signs  of  mental  impairment,  and 
lived  for  73^  years  after  admission. 

The  medical  certificate  stated  that  he  had  an  uncontrollable 
temper,  had  hysterical  attacks,  delusions  of  persecution  and  loss 


6o  SHEPHERD  IVORY  FRANZ 

of  memory.  Physically  there  were:  sHght  peripheral  arterios- 
clerosis ;  hearing  was  very  much  diminished ;  the  voluntary  move- 
ments were  normal  in  accuracy  and  rapidity,  but  they  lacked 
force;  the  knee  jerks  were  absent.  The  family  and  previous 
personal  history  was  poor  because  the  patient's  memory  for  re- 
cent and  remote  events  was  defective  and  what  was  obtained 
showed  nothing  of  interest  or  importance.  The  patient's  expres- 
sion was  stupid,  he  was  rather  untidy,  he  appeared  to  be  simple- 
minded  and  rather  childish ;  usually  he  was  good  natured,  happy 
and  contented,  but  at  times  he  was  irritable  and  abusive ;  he  was 
very  industrious  making  baskets  which  he  tried  to  sell ;  he  talked 
and  associated  with  the  other  patients  in  a  normal  manner;  his 
memory  for  recent  and  remote  events  was  not  good,  but,  on  the 
other  hand,  was  not  entirely  absent;  he  conversed  coherently, 
relevantly  and  freely;  he  was  oriented,  showed  fairly  good  judg- 
ment, but  exhibited  no  insight.  Fluid  accumulated  in  the  ab- 
domen and  for  this  he  was  tapped  twice,  but  died.  At  the  autopsy 
the  chief  findings  were:  fifteen  liters  of  fluid  in  the  abdominal 
cavity;  marked  sclerosis  of  the  abdominal  aorta;  peritonitis; 
sclerosis  of  the  liver  and  kidney;  and  marked  shrinkage  of  the 
anterior  cerebral  convolutions. 

Case  34,  white  male,  exhibited  mental  changes  for  nearly  3 
years  previous  to  his  admission  to  the  Hospital  at  the  age  of  80 ; 
and  lived  i  year  2^  months  subsequently. 

The  patient's  family  history  and  the  account  of  his  previous 
life  were  not  well  obtained,  but  what  was  learned  was  unimpor- 
tant. The  medical  certificate  reported  him  to  be  childish,  restless, 
inclined  to  wander  away  and  become  lost.  His  general  attitude 
was  one  of  weakness,  or  weariness  and  fatigue;  his  gait  was 
shuffling,  and  slow;  he  had  impaired  vision  (beginning  cataract)  ; 
and  defective  speech.  Neurologically  he  showed:  arcus  senilis; 
unequal  pupils,  the  left  failed  to  react  to  light;  the  knee  jerks 
were  diminished;  there  was  a  slight  ankle  clonus;  there  were 
tremors  of  the  tongue,  lips  and  face ;  a  slight  Romberg  was  pres- 
ent.    He  was  noted  to  be  harmless,  agreeable,  and  cooperative; 


SYMPTOM ATOLOGICAL  DIFFERENCES  IN  THE  INSANE      6l 

he  was  absolutely  disoriented;  his  memory  was  very  poor  both 
for  recent  and  remote  events;  he  was  somewhat  confused  and 
was  easily  upset;  emotionally  he  was  unstable,  and  occasionally 
irritable,  and  possibly  on  the  borderline  of  depression;  he  had 
nothing  to  say  voluntarily;  he  preferred  to  be  let  alone  and  he 
sat  in  one  corner  and  did  not  associate  with  the  other  patients ;  he 
appeared  to  have  fair  insight  into  his  condition ;  his  general  com- 
prehension, reasoning  and  judgment  did  not  seem  impaired  when 
his  mind  was  occupied  with  simple  things;  his  mental  associa- 
tions were  not  very  active;  his  ideation  was  limited  in  amount; 
he  paid  little  or  no  attention  to  his  environment.  He  became 
untidy,  refused  to  answer  questions  and  used  profane,  vulgar  and 
abusive  language  to  his  questioners.  The  autopsy  showed :  slight 
atrophy  of  the  anterior  cerebral  convolutions,  but  no  other  gross 
cerebral  lesions ;  aorta  and  aortic  valves  atheromatous ;  bronchitis ; 
pulmonary  tubercular  nobules;  pulmonary  emphysema;  cirrhosis 
of  the  liver ;  fibrous  spleen  and  kidney ;  the  right  adrenal  contained 
an  overgrowth  and  an  hemorrhagic  area. 

Case  35,  white  male,  has  been  mentally  changed  for  a  year  pre- 
vious to  admission,  at  the  age  of  61.  Hospital  residence  was  11 
years  and  2  months. 

This  patient  was  sent  to  the  Hospital  on  account  of  de- 
lusions of  "strange  and  impossible  happenings"  and  hallucina- 
tions of  hearing  (fictitious  voices)  and  of  vision  (mysterious 
objects).  Physically  he  showed  a  dilated  heart,  bleeding 
hemorrhoids,  and  a  right  inguinal  hernia.  Neurologically  his 
movements  were  deliberate,  slow  and  rather  weak;  his  coordina- 
tion seemed  somewhat  impaired,  although  his  gait  was  firm  and 
steady;  a  slight  fibrillary  tremor  of  the  tongue  was  observed; 
hearing  was  defective.  He  appeared  to  comprehend  what  was 
said  to  him,  but  was  deliberate  in  answering;  his  memory  was 
good,  somewhat  'better  for  remote  than  for  recent  events;  his 
reasoning  and  judgment  appeared  to  be  below  par;  he  heard 
voices  outside  his  door  at  night;  he  was  mildly  depressed  but 
claimed  to  be  fairly  well  satisfied  with  his  surroundings   (ex- 


6a  SHEPHERD  IVORY  FRANZ 

cept  for  his  delusions) ;  he  also  showed  some  irritability. 
Later  he  became  more  irritable,  and  at  times  he  was  ugly 
and  insulting;  he  refused  to  answer  questions;  he  was  dis- 
trustful and  suspicious,  and  exhibited  delusions  of  perse- 
cution (he  claimed  that  the  physicians  had  him  "wired,"  that 
they  conspired  to  keep  him  in  the  Hospital,  and  hold  him  for 
robbery  and  mistreatment;  and  he  refused  to  converse  with 
them)  ;  he  claimed  that  the  patients  ought  to  be  sent  to  school  and 
educated ;  he  was  oriented ;  he  was  tidy ;  he  was  usually  quiet  and 
orderly,  but  occasionally  he  became  indignant,  irritable  and 
wrought  up  over  his  detention.  Delusions  of  grandeur  were 
added  to  those  of  persecution  (he  thought  himself  to  be  a  very 
rich  man  and  that  the  Government  was  robbing  him  of  thousands 
of  dollars  daily)  ;  his  memory  became  poor;  he  was  disoriented 
for  time;  when  talking  with  the  physicians,  regarding  whom  he 
had  delusions,  he  became  so  emotional  that  his  voice  trembled ;  he 
refused  to  answer  questions  regarding  his  condition;  he  was 
usually  quiet,  orderly  and  well-behaved  except  when  approached 
by  one  regarding  whom  he  had  delusions;  later  he  believed  the 
attendants  were  putting  poison  into  his  food  and  drinks,  trying 
to  shave  him  against  his  will  and  injure  him  in  other  ways ;  insight 
into  his  condition  was  lacking.  Death  was  due  to  cardiovascular 
and  renal  diseases;  the  autopsy  also  showed  shrinkage  of  the 
cerebral  convolutions  over  the  anterior  two-thirds  and  athero- 
matous cerebral  vessels. 

Case  36,  colored  female ;  the  duration  of  the  mental  disease  at 
the  time  of  admission  was  not  stated  in  the  medical  certificate; 
she  lived  in  the  Hospital  7  years  and  5  months. 

The  age  of  this  patient  was  unknown,  but  she  was  undoubtedly 
old  at  the  time  she  was  admitted  from  the  Alms  House ;  there  she 
had  been  observed  to  be  "maniacal,"  i.e.,  very  much  excited ;  she 
could  not  answer  questions  intelligently  and  at  times  showed  that 
she  had  delusions  that  people  were  after  her;  she  was  noisy, 
especially  at  night.  Her  facial  expression  was  one  of  apathy; 
her  gait  was  slow  and  feeble;  the  physical  examination  showed 
nothing  abnormal;  neurologically  she  showed  fine  tremors  of 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      63 

the  extremities,  sight  and  hearing  were  defective.  She  was 
somewhat  disoriented  and  there  was  some  clouding  of  con- 
sciousness; she  did  not  appear  to  appreciate  her  surroundings; 
her  memory  for  remote  events  was  fair,  but  poor  for  recent 
events;  in  talking  she  lapsed  into  incoherency,  goal  ideas  were 
lost;  her  reasoning  and  judgment  were  impaired;  she  thought 
she  could  talk  with  the  Lord,  and  she  became  religiously  excited 
at  times,  but  as  a  rule  she  sat  quietly  in  the  ward,  taking  no  in- 
terest ;  she  was  tidy  in  habits.  She  exhibited  the  signs  of  gradual 
mental  enf  eeblement ;  memory  became  practically  a  blank,  and  she 
became  untidy  in  habits;  she  did  not  want  to  be  interfered  with 
by  the  nurses,  and  occasionally  she  showed  a  rather  cross  and 
irritable  disposition;  she  sat  in  one  chair  with  an  apron  over  her 
head  for  hours;  she  never  spoke  unless  spoken  to  and  then  al- 
ways complained  of  being  burned  up  by  fire ;  the  reason  for  cover- 
ing her  head  could  not  be  learned.  Death  was  due  to  pulmonary 
hypostasis  and  hemorrhagic  cystitic;  the  autopsy  showed  in 
addition  generalized  arteriosclerosis,  cardiac  atrophy,  chronic 
diffuse  nephritis  and  atrophy  of  the  anterior  two-thirds  of  the 
cerebral  convolutions. 

Case  37,  white  male,  had  been  mentally  deranged  for  2  years 
previous  to  his  admission  at  the  age  of  74;  he  lived  in  the  Hospi- 
tal 3  years  and  2  months. 

The  family  history  was  negative.  At  the  age  of  43,  as  a 
veteran  of  the  Civil  War,  he  was  admitted  to  a  Soldiers'  Home,  for 
"physical  disability  and  mental  incapacity."  The  physical  dis- 
ability was  a  contusion  df  the  right  shoulder;  the  character  of 
the  mental  incapacity  was  not  noted,  but  could  not  have  been  a 
marked  mental  change  since  the  patient  was  able  to  take  care  of 
himself  and  was  permitted  to  go  at  will.  Twenty-four  years 
later,  at  the  age  of  67,  he  was  noted  to  have  "impaired  cerebra- 
tion," but  this  term  is  not  defined ;  six  years  subsequently  he  was 
noted  to  be  senile;  to  have  impaired  cerebration  and  delusions  of 
persecution  (he  thought  he  was  to  be  hanged  for  misdemeanors 
of  which  he  was  not  guilty)  ;  he  was  inclined  to  be  talkative,  but 
his  conversation  was  disconnected ;  there  was  inability  to  concen- 


64  SHEPHERD  IVORY  FRANZ 

trate  his  thoughts;  he  showed  impaired  judgment  and  reasoning. 
On  one  occasion  a  rope,  carefully  and  securely  fixed,  was  found 
in  his  locker,  although  it  is  not  known  that  he  had  attempted  or 
planned  suicide.  Physically  he  was  quite  active  for  his  age,  and 
his  physical  condition  good  with  the  exception  of  difficulty  of  hear- 
ing and  right  inguinal  hernia.  On  admission  he  was  restless  and 
confused ;  he  showed  no  interest  in  his  surroundings ;  he  was  un- 
tidy in  appearance,  but  tidy  in  habits ;  it  was  difficult  to  make  him 
understand,  and  he  failed  to  answer  questions ;  no  delusions  could 
be  elicited,  although  he  appeared  to  be  apprehensive  and  afraid 
that  any  one  who  approached  him  would  do  him  harm ;  his  con- 
sciousness was  clouded;  he  was  disoriented  for  time  and  place; 
his  memory  and  intellect  were  very  much  impaired;  his  emotional 
tone  was  one  of  indifference.  Soon  he  became  untidy  in  habits, 
and  there  remained  to  him  only  a  remnant  of  his  former  knowl- 
edge ;  he  was  kept  in  bed ;  he  took  no  interest  in  his  surroundings ; 
when  approached  and  questioned  he  cried  and  whined  pitifully, 
he  volunteered  no  information  and  he  answered  few  questions; 
he  was  entirely  disoriented;  he  seemed  to  remember  the  events 
of  his  childhood  but  none  of  recent  date;  no  delusions  or  hallu- 
cinations could  be  elicited.  He  was  restless  and  pulled  and  re- 
arranged his  bed  clothing  frequently  and  resisted  attempts  to 
help  him.  Death  was  due  to  bronchopneumonia.  The  autopsy 
showed  marked  shrinkage  of  the  frontoparietal  convolutions. 

Case  38,  white  male,  was  admitted  to  the  Hospital  at  the  age  of 
y2 ;  his  mental  disturbance  began  2  months  previous  to,  and 
he  lived  only  i  month  after  his  admission. 

For  two  months  previous  to  admission  the  patient  was  childish, 
forgetful,  disoriental,  and  had  a  depression.  His  family  history, 
as  far  as  it  could  be  ascertained,  was  negative.  Physically  he 
showed  slightly  enlarged  heart,  double  arcus  senilis,  and  defec- 
tive hearing;  Wassermann  reaction  with  the  blood  serum  was 
negative;  albumin  and  casts  were  found  in  the  urine.  Neurolo- 
gically  he  showed  :  sluggish  accommodation  reactions,  and  irregu- 
lar pupils;  deep  reflexes  diminished;  slight  Romberg  sign;  gait 
was  very  feeble;  muscles  wasted  and  atrophic;  voluntary  move- 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE     65 

ments  feeble ;  irregular  tremors  of  the  fingers.  Mentally  he  said 
he  was  sad,  but  usually  he  appeared  to  be  indifferent;  he  had  a 
poor  memory ;  he  was  not  oriented  for  persons,  and  only  partially 
for  time  and  place ;  insight  was  lacking ;  no  hallucinations  or  delu- 
sions were  elicited;  his  speech  was  good.  The  patient  developed 
diarrhoea  and  died  from  exhaustion;  the  autopsy  revealed  no 
arteriosclerosis ;  the  cerebral  convolutions  were  shrunken  over  the 
frontal  lobes  and  the  posterior  portions  of  the  parietal  lobes,  but 
section  of  the  brain  showed  no  other  changes;  aortic  atheroma; 
pulmonary  tuberculosis;  and  parenchymatous  nephritis. 

Senile  Dementia,  Discussion 

These  fourteen  cases  are  not  entirely  alike  as  far  as  lesions  are 
concerned,  and,  it  will  be  noted,  some  diagnostic  questions  have 
been  raised  regarding  some  of  them.  Case  28  has  been  noted 
as  being  a  possible  alcoholic  psychosis,  and  some  of  the  hallucina- 
tions which  this  patient  had  are  suggestive  of  the  alcoholic  de- 
lirium. Patients  29,  30,  and  ^y  were  also  considered  at  one  time 
to  be  rather  doubtful.  Patient  29  was  admitted  to  the  Hospital 
for  the  first  time  at  the  age  of  56,  was  su'bsequently  discharged, 
but  readmitted  at  the  age  of  69.  Patient  30,  on  the  other  hand, 
had  been  noted  to  have  had  "nervous  prostration"  eleven  years 
previous  to  his  admission  to  the  Hospital,  but  the  symptoms  which 
he  exhibited  at  that  time  were  not  recorded,  and  it  is  impossible 
to  determine  the  nature  of  the  condition.  Since  the  term  "nervous 
prostration"  is  so  inaccurately  used  by  general  practitioners,  it  is 
difficult  to  be  certain  that  the  patient  exhibited  anything  more 
than  a  disinclination  for  mental  and  physical  work.  Patient  2y 
also  had  been  noted  as  exhibiting  "mental  incapacity"  thirty-one 
years  previous  to  his  admission  to  the  Hospital,  but,  as  has  been 
noted  in  the  case  history,  this  was  probably  a  very  general  term, 
and  it  may  have  been  only  a  means  of  having  him  enrolled  as  an 
inmate  of  the  Soldiers'  Home  in  which  he  spent  these  years.  Pa- 
tient 31  had  epileptiform  convulsions,  but  no  previous  history  of 
disturbances  of  this  nature  was  obtained,  and  it  is  likely  that 
these  convulsive  seizures  were  due  to  the  degenerative  cerebral 
conditions  which  mentally  resulted  in  the  dementia. 


66  SHEPHERD  IVORY  FRANZ 

Regarding  the  cerebral  conditions,  similar  variations  are  noted. 
Patient  28  exhibited  what  appeared  to  be  an  unilateral  atrophy  on 
the  left  side  of  the  cerebrum.  The  description  of  the  atrophy  in 
case  37  is  probably  to  be  taken  to  be  the  equivalent  of  that  which 
has  been  noted  in  cases  35  and  36,  namely,  that  it  covered  the 
frontal,  central  and  parietal  regions  of  the  brain,  in  this  way 
taking  in  approximately  two-thirds  of  the  convexity.  The  brain 
of  patient  38,  like  that  of  patient  28,  also  showed  rather  circum- 
scribed atrophies,  and  it  has  been  noted  that  these  were  in  the 
posterior  parietal  lobes  as  well  as  in  the  frontal  lobes.  This  case 
is  added  for  the  purpose  of  comparison  with  those  cases  which 
are  strictly  frontal  atrophies,  and  for  the  purpose  of  comparison 
with  the  extensive  lesions  which  were  found  in  cases  35,  36,  and 
37.  The  degree  of  atrophy  in  these  cases  was  varied,  cases  28,  29, 
and  34  exhibiting  only  a  slight  amount  of  atrophy  while  cases  31 
and  2)2)  showed  a  marked  degree  of  shrinkage. 

In  general  the  mentality  of  these  patients  did  not  greatly  differ. 
All  showed  a  considerable  degree  of  dementia.  They  had  little 
intelligence  or  understanding  of  what  went  on  about  them;  they 
were  at  times  unable  to  answer  questions ;  they  had  become  child- 
ish, slovenly  in  appearance,  and  they  wandered  around  the  wards 
aimlessly.  At  the  same  time,  they  were  mostly  harmless  and 
usually  quiet,  agreeable,  and  sometimes  apparently  stupid,  but  at 
times  they  became  restless  and  irritated.  Patient  34,  who  ex- 
hibited only  a  slight  degree  of  atrophy  of  the  frontal  regions,  was 
apparently  as  demented  as  any  of  the  other  cases,  and  patients 
28  and  29,  whose  brains  were  also  noted  to  exhibited  only  slight 
atrophies,  were  at  the  same  time  considerably  demented.  On  the 
other  hand,  the  marked  degree  of  cerebral  atrophy  which  was 
found  in  the  brains  of  patients  31  and  33  did  not  appear  to 
bring  about  any  greater  degree  of  dementia  or  loss  of  mentality 
than  in  the  other  cases.  These  two  patients  were  confused  or 
wandered  away,  or  were  stupid,  simple-minded  or  childish,  but 
in  these  respects  they  were  not  any  less  mentally  active  or  men- 
tally endowed  than  patient  25,  who  was  noted  to  exhibit  "no 
intelligent  understanding,"  or  than  patient  26,  who  was  quiet, 
confused,  or  than  patient  27,  who  was  childish  and  wandered 


SYMPTOMATOLOGICAL  DIFFERENCES  IM  THE  INSANE      67 

away.  The  relation  of  the  general  mental  condition  Oi  dementia 
to  the  frontal,  or  to  the  distributed  anterior,  or  to  the  even  more 
extensive  frontal-parietal  atrophies  is  not  a  definite  one,  and  it  is 
apparent  that  in  these  cases,  as  well  as  in  those  which  have  pre- 
viously been  considered,  the  relation  of  the  degree  of  atrophy  to 
the  degree  of  dementia  is  not  simple. 

Most  of  these  patients  exhibited  rather  marked  degrees  of 
motor  disorder.  Tremors  of  the  hands,  tongue,  face,  or  fingers 
were  found  in  nine  of  these  patients,  and  it  is  of  interest  to  note 
that  with  the  exception  of  patient  29  the  frontal  cases  showed 
these  disturbances  as  much  as  those  cases  in  which  the  atrophies 
extended  beyond  the  limits  of  the  frontal  lobes.  In  fact,  those 
patients  whose  brains  were  found  to  have  the  more  extensive 
atrophies  (patients  31,  33  and  37)  did  not  show  motor  distur- 
bances of  this  character.  Patients  27,  29,  33,  and  37  were  active 
for  individuals  of  their  age,  and  although  in  connection  with 
general  muscular  atrophy  they  usually  showed  a  slight  amount  of 
force  in  their  movements,  their  movements  were  accurate  and 
quick.  It  will  be  seen  that  some  of  these  patients  were  those  in 
which  the  precentral  region  was  also  included  in  the  atrophic 
zone.  In  these  cases,  aside  from  the  tremors,  the  five  patients 
with  frontal  atrophies  (including  case  38)  were  apparently  motor- 
ially  more  capable  than  those  patients  with  the  more  extensive 
atrophies.  This,  however,  is  only  true  in  a  general  way.  The 
cases  showed  such  extensive  divergences  in  this  particaular  that 
they  can  not  be  considered  to  be  correlated  with  any  special  de- 
gree or  with  any  special  extent  of  the  pathological  conditions  of 
cerebral  atrophy. 

The  conversation  of  most  of  these  patients  was  disconnected 
and  frequently  incoherent.  Their  remarks  were  often  almost 
unintelligible.  They  answered  questions  in  an  irrelevant  manner, 
sometimes  slowly  or,  as  it  has  been  described,  deliberately,  and  at 
times  they  refused  to  answer  or  failed  to  answer  at  all.  These 
variations  from  the  normal  activity  were  found  in  practically  all 
these  fourteen  cases,  although  there  is  one  exception,  viz.,  patient 
38,  who  not  only  answered  properly  and  intelligently,  but  his 
speech,  i.e.,  his  enunciation  was  good.     In  the  case  of  speech  as 


€6  SHEPHERD  IVORY  FRANZ 

distinguished  from  conversation,  it  was  'found  that  many  of  these 
cases  exhibited  no  specific  alterations,  although  patient  29  has 
been  described  as  having  been  unable  to  repeat  test  phrases,  and 
patient  34  was  noted  to  exhibit  defective  speech. 

The  emotional  tone  of  patients  2y  and  28  is  not  specifically 
mentioned,  and  conclusions  regarding  their  conditions  in  this  re- 
spect must  be  drawn  from  the  other  facts  in  the  case  histories. 
We  may  conclude  from  the  general  accounts  that  patient  2y 
was  usually  cheerful,  but  at  times,  on  account  of  his  delusions, 
apparently  depressed,  and,  as  has  been  noted  in  the  account  given 
above,  he  was  occasionally  excited,  disagreeable  and  pugnacious. 
The  hallucinations  which  were  evident  in  patient  28  and  the  delu- 
sions which  he  gave  voice  to  did  not  appear  to  bring  about  very 
marked  emotional  reactions,  although  he  was  excited  at  times. 
As  a  rule,  the  other  patients  were  usually  indifferent;  they  were 
quiet ;  some  of  them  were  stupid,  childish,  and  as  may  be  concluded 
from  their  general  mental  symptoms,  they  ranged  in  their  affec- 
tive states  from  indifference  to  excitability,  or  to  feelings  of  well- 
being,  or  to  a  depression  or  sadness.  Patient  25  was  perhaps  the 
only  one  who  exhibited  no  evident  emotional  reaction,  although 
it  should  be  remarked  that  he  laughed  and  smiled  spasmodically. 
Externally  he  appeared  to  be  emotionally  labile,  but  in  reality  he 
had  no  apparent  affective  concomitant  with  these  reactions.  The 
relation  of  these  emotional  conditions  to  the  extents  and  degrees 
of  atrophy  is  not  apparent.  Those  patients  with  frontal  lesions 
appeared  to  be  as  much  affected  as  those  with  the  more  extensive 
lesions,  and  the  condition  of  marked  atrophy  in  patients  31  and 
33,  it  will  be  noted,  did  not  give  rise  to  any  special  degree  or 
character  of  affective  phenomena. 

Eight  ai  these  patients  showed  at  no  time  any  evidence  of  hallu- 
cinations. The  other  six  patients  did  have  hallucinations,  with 
a  possible  exception  of  patient  26.  The  latter  patient,  as  the 
case  history  shows,  laughed  and  talked  to  himself  and  had  delu- 
sions of  driving  horses  or  of  calling  to  them,  and,  like  patient  22, 
he  was  found  calling  to  horses  as  if  he  were  taking  care  o'f  or 
driving  them.  Whether  these  symptoms  should  be  interpreted  to 
be  entirely  delusionary  or  to  be  partially  hallucinatory,  as  if  he 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE     69 

had  the  particular  sensations  in  the  hands  and  arms  of  driving  or 
of  rubbing  down  the  horses,  or  of  the  visual  experiences  of  seeing 
the  horses,  cannot  be  determined.  It  appears  probable,  however, 
that  the  delusion  of  his  taking  care  of  and  driving  these  animals 
was  due  to  the  presence  of  hallucinations  as  much  as  to  anything 
else.  The  hallucinations  of  patient  28  are  much  like  those  of  the 
alcoholic  delirium,  as  has  been  noted  above.  The  hallucinations 
of  alligators  and  snakes  were  especially  like  those  which  a  patient 
with  delirium  tremens  experiences,  and  the  evident  disorientation 
regarding  the  seasons  when  he  complained  of  the  cold  weather, 
with  snow  on  the  ground,  when  in  reality  it  was  bright  and  warm, 
and  when  he  complained  of  his  being  without  shoes  and  clothing 
with  the  snow  up  to  his  knees,  appeared  to  be  much  more  like  the 
paresthesias  which  an  alcoholic  might  have.  This  apparent  delu- 
sion, or  disorientation  for  time,  appeared,  therefore,  to  be  much 
more  like  a  tactual  paresthesia,  or  to  be  dependent  upon  such  a 
condition,  although  it  is  not  certain  that  we  can  exclude  the  visual 
element.  In  the  expression  df  her  delusions  patient  36  also  gave 
evidence  that  she  had  paresthesias,  for  it  will  be  rememtyered  that 
she  complained  of  being  burned  up  by  fire.  It  is  also  possible  that 
her  delusion  regarding  her  ability  to  talk  with  the  Lord  may  have 
had  as  a  basis  the  presence  of  auditory  hallucinations  of  voices. 
Patients  30  and  31  at  the  time  of  their  entrance  to  the  Hospital 
were  noted  to  be  free  'from  hallucinations,  but  at  a  later  date  both 
of  these  patients  gave  evidence  of  the  presence  of  these  abnormal- 
ities. Patient  30  complained  that  he  heard  voices  at  night.  At  the 
same  time  it  should  be  remembered  that  he  also  complained  that 
electricity  had  been  used  upon  him,  which  had  prevented  his 
urination.  Patient  31  was  found  trying  to  pick  imaginary  objects 
from  the  floor.  Whether  or  not  this  reaction  was  due  to  a  visual 
hallucination  or  to  a  combination  of  visual  and  tactile  hallucina- 
tions was  not  determined.  The  delusion  of  patient  30  regarding 
the  action  of  electricity  was  undoubtedly  of  an  hallucinatory  na- 
ture, as  has  been  mentioned,  the  particular  hallucination  being  of 
the  organic  type.  It  is  of  interest  in  this  connection  to  note  that 
these  patients  who  exhibited  hallucinations  showed  these  abnor- 
malities more  frequently  in  the  field  of  the  skin  sensations  than 


70  SHEPHERD  IVORY  FRANZ 

in  other  fields.  From  what  we  know  regarding  the  functions  of 
the  postcentral  areas  of  the  brain  it  might  be  expected  that  this 
kind  of  hallucination  would  be  more  common  in  those  patients 
who  exhibited  atrophy  in  the  parietal  region,  viz.,  patients  35, 
36,  and  2)7,  but  of  these  three  patients  only  one  had  hallucinations 
df  this  character.  This  woman  complained  of  being  burned  up 
by  fire.  Patients  26  and  28,  whose  brains  were  only  atrophied 
in  the  frontal  lobes,  also  had  the  same  kind  of  delusions,  appar- 
ently based  upon  tactile  or  organic  hallucinations.  From  these 
facts  it  appears  that  the  hallucinations  in  these  cases  are  not  di- 
rectly connected  with  the  degree  or  the  extent  of  the  atrophies 
which  have  been  recorded. 

Three  of  the  patients  were  entirely  free  from  delusions  of  any 
kind.  Two  others,  patients  25  and  37,  were  somewhat  doubtful, 
although  it  appears  that  patient  25  in  mistaking  individuals  and 
calling  them  by  names  not  their  own  was  suffering  from  a  defect 
of  memory  or  o'f  orientation  for  persons,  and  did  not  have,  pri- 
marily, a  delusion.  It  is  impossible  in  the  case  of  patient  37  to 
determine  whether  the  ideas  of  persecution  which  he  spoke 
of  were  or  were  not  delusions.  At  any  rate,  they  were  not  par- 
ticularly evident,  although  it  should  be  remembered  that  he 
frequently  appeared  to  be  apprehensive,  as  if  some  harm  would 
happen  to  him  or  as  if  he  were  being  persecuted.  Delusions  of 
persecution  were  also  found  in  patients  26,  28,  30,  33,  35,  and  36. 
These  gave  way  to  delusions  of  grandeur  or  of  exaltation  in  the 
case  of  patient  35,  and  perhaps  also  in  the  case  of  patient  36. 
Delusions  of  grandeur  were  also  given  expression  by  patients  27, 
29,  and  31.  Although  patients  25,  30,  and  31  did  not  show  any 
evidence  of  the  presence  of  delusions  at  the  time  of  their  admis- 
sion to  the  institution,  at  later  dates  delusions,  of  which  mention 
has  been  made  in  the  individual  case  histories,  were  in  evidence. 
The  association  of  delusions  with  lesions  of  the  frontal  region, 
in  view  of  the  lack  of  these  abnormalities  in  cases  32,  34,  and  38, 
and  possibly  also  37  and  25,  can  not  be  said  to  be  demonstrated 
by  these  series  of  cases.  If  we  believe  that  the  "Personenverken- 
nung"  of  patient  25  to  be  a  real  delusion,  we  can  conclude  that  all 
of  the  simple  frontal  cases  exhibited  delusions.    Opposed  to  this, 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      71 

however,  is  the  fact  that  the  extension  of  the  atrophies  beyond 
the  frontal  region  in  the  other  nine  cases  did  not  always  result  in 
delusions.  Case  38  is  particularly  interesting  in  this  connection 
because  the  frontal  region  was  undoubtedly  atrophied,  and  added 
to  this  atrophy  there  was  an  atrophy  of  the  posterior  portion  of 
the  parietal  region.  If  frontal  lesions  in  themselves  were  espe- 
cially allied  to  the  delusion  formation,  it  is  to  be  expected  that 
the  more  extensive  atrophy  would  have  been  accompanied  by  this 
mental  condition.  Such,  however,  was  not  found.  In  these  cases, 
therefore,  delusions  appear  not  to  be  directly  associated  with  a 
particular  location  or  a  particular  degree  of  atrophy. 

Patient  29,  who  showed  only  a  slight  frontal  atrophy,  ex- 
hibited an  accurate  and  exact  memory.  Patient  35,  especially 
during  his  early  Hospital  residence,  was  also  'found  to  have  a  good 
memory,  and  although  patient  30  was  noted  as  having  an  imper- 
fect memory  at  the  time  of  his  admission,  it  will  be  noted  that 
according  to  the  case  history  his  memory  varied  from  "good" 
to  "poor"  during  his  later  Hospital  residence.  At  times  he  ap- 
peared to  have  a  very  good  grasp  upon  his  surroundings,  to 
know  the  events  of  his  past  life  as  well  as  other  events,  and  at 
other  times  he  did  not  appear  to  remember  these  things.  In 
the  other  cases  memory  was  poor.  In  the  cases  of  patients 
36  and  37  memory  for  remote  events,  especially  those  of  their 
childhood,  was  fair,  but  for  more  recent  occurrences  memory 
was  bad.  When  we  consider  these  phenomena  in  connection 
with  the  extent  and  degree  of  the  atrophies  which  the  brains 
of  these  patients  exhibited,  there  appears  to  be  no  correlation 
whatsoever. 

Case  33  was  the  only  patient  who  was  completely  oriented,  and 
this  is  particularly  noticeable  in  view  of  the  extent  and  degree  of 
atrophy  in  his  brain.  Nine  of  the  other  cases  were  completely 
disoriented  for  time,  for  place,  and  for  persons.  Patient  29, 
with  a  slight  frontal  atrophy,  was  disoriented  for  time,  and 
similarly  patient  35,  while  patient  38  was  disoriented  for  persons 
and  only  partially  disoriented  for  time  and  for  place.  Patient 
30  exhibited  the  same  kind  of  fluctuation  regarding  this  mental 
function  as  he  did  for  memory,  in  that  at  times  he  appeared  to 


72  SHEPHERD  IVORY  FRANZ 

be  completely  disoriented,  to  know  nothing  of  time  or  of  place 
or  of  persons,  and  again  to  have  an  excellent  grasp  upon  these 
things.  In  this  way  there  appeared  to  be  fluctuations  in  his 
mental  condition,  and  these  have,  as  far  as  can  be  determined, 
no  direct  correspondence  with  the  cerebral  lesions  in  his  case. 
The  abnormalities  in  this  field  do  not  apparently  depend  upon 
the  character  or  degree  of  the  atrophies,  the  opposing  evidence 
shown  in  case  33  alone  being  such  as  would  prevent  any  definite 
statement  regarding  a  relation. 

Nine  of  these  patients  lacked  insight.  One,  patient  34,  had 
fair  insight  into  his  condition,  whereas  the  other  four  cases  had 
what  might  be  termed  partial  insight  in  that,  in  answers  to 
questions,  they  gave  evidence  that  they  recognized  that  something 
was  wrong  with  them.  They  were  incapable  of  making  any 
kind  of  analysis,  and  in  at  least  some  of  the  cases  it  is  not 
certain  that  their  remarks  should  be  interpreted  as  evidence  of 
insight.  Thus,  patient  26  appeared  to  have  no  insight  into  his 
condition  except  that  he  remarked  at  one  time  that  if  the  ques- 
tions had  been  asked  him  a  month  previously,  he  would  have 
been  able  to  answer  them.  Patients  28  and  32  were  more  evi- 
dently in  a  condition  in  which  they  appreciated  that  something 
was  wrong  with  their  minds,  for  both  admitted  that  there  were 
"things  in  their  minds  which  were  not  right,"  and  that  their 
minds  were  afifected  in  some  manner.  There  appears  to  be  some 
relation  between  the  degree  of  brain  shrinkage  and  general 
insight  in  that  in  every  case  in  which  there  was  a  slight  degree 
oif  atrophy  insight  was  present,  partially  at  least.  Insight,  how- 
ever, as  related  to  the  extent  of  atrophy,  does  not  appear  to  have 
much  correlation,  although  of  the  five  frontal  cases  three  did 
exhibit  some  insight  into  their  condition,  while  of  the  anterior 
atrophies  only  two  exhibited  insight,  and  of  the  four  remain- 
ing cases  none  exhibited  insight  in  any  degree. 

Some  of  the  other  abnormalities  which  have  been  recorded 
in  the  case  histories  may  have  relations  to  the  sensory  defects 
which  were  present  in  these  patients,  although  this  is  not  ap- 
parent. Apprehensiveness,  or  delusions,  or  feelings  of  depression 
or  apathy  may  be  due  to  the  presence  of  defects  of  hearing. 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      73 

which  abnormality  was  found  in  eight  of  these  cases,  and  which 
in  otherwise  normal  individuals  appears  at  times  to  be  associated 
with  suspiciousness  and  allied  affective  states.  It  will  be  re- 
membered that  patient  28  had  some  impairment  of  the  skin 
sensations,  and  it  is  possible  that  his  hallucinations  and  his 
delusions  of  disorientation,  snow  on  the  ground,  etc.,  which 
have  been  described  in  a  previous  paragraph,  may  have  been 
due  to  the  hypoesthesia  for  skin  sensations.  At  the  same  time 
it  should  be  recalled  that  patient  27  and  patient  34  exhibited 
signs  of  beginning  cataract,  but  these  visual  defects  did  not 
bring  about  any  types  of  visual  hallucinations  or  delusions. 
It  is  unfortunate  that  the  "impairment  of  perception"  noted  in 
patient  30  is  not  more  fully  described,  for  it  is  possible  that 
there  were,  in  his  case,  sensory  abnormalities  which  may  have 
had  certain  relations  with  the  delusions  and  hallucinations  of 
which  this  patient  gave  evidence.  The  impairment  of  skin 
sensations  in  patient  28  is  not  correlated  with  atrophy  of  the 
postcentral  region,  since  it  will  be  remembered  that  this  patient 
exhibited  only  a  slight  atrophy  in  one  hemisphere. 

When  we  deal  with  these  patients  as  a  group,  we  find,  as  in 
the  other  psychoses,  extensive  atrophies  associated  with  some 
mental  conditions  quite  similar  to  those  found  in  the  patients 
with  the  less  extensive  atrophies.  In  general  it  may  be  said 
that  the  exaggerated  atrophies  have  given  rise  to  -no  more 
prominent  symptoms  than  the  milder  or  slight  degrees  of 
atrophy  which  were  recorded  as  being  present  in  the  brains 
of  three  of  these  patients. 


SUMMARY 

Although  all  the  cases  which  have  been  studied  exhibited 
atrophies  which  always  included  the  frontal  cerebral  convolu- 
tions, and  some  also  included  atrophies  of  the  neighboring 
central  and  parietal  portions  of  the  cerebrum,  no  one  symptom 
was  found  to  be  constant,  with  the  possible  exception  di  that 
complex  condition  which  is  called  dementia.  It  is  also  to  be  noted 
that  although  the  degree  of  atrophy  varied  from  "slight"  to 
"marked"  no  one  symptom  or  degree  of  symptom  was  found 
to  correspond  with  these  cerebral  changes.  In  general,  there- 
fore, we  may  say  that  there  is  no  apparent  correlation  between 
the  extent  or  the  degree  of  atrophy  and  the  general  mental 
condition.  Those  individuals  who  exhibited  only  frontal 
atrophies  at  times  showed  as  much  dementia  as  those  in  which 
the  atrophy  was  more  extensive,  and  many  of  the  cases  in 
which  the  atrophy  was  of  a  slight  nature  were  also  as  demented 
as  those  in  which  the  atrophy  was  noted  to  be  great. 

Nor  does  there  appear  to  be  any  correlation  between  the 
form  of  the  disease  in  the  individual  groups  and  the  extent 
or  the  degree  of  the  cerebral  atrophy.  It  is  true  that  more 
of  the  dementia  precox  group  with  anterior  atrophies  were 
catatonic  in  nature  and  that  more  of  the  frontal  cases  appeared 
to  be  rather  paranoid.  On  the  other  hand,  both  with  frontal 
and  anterior  atrophies,  sufficient  cases  with  other  forms  of  the 
disease  were  observed,  and  it  seems  certain  that  the  extent 
of  the  atrophy  is  not  the  determining  element  in  the  production 
of  the  collection  of  symptoms  which  give  warrant  for  the 
diagnosis  of  the  "form"  of  the  disease.  For  the  arteriosclerotic, 
senile  and  paretic  groups  of  cases  a  similar  statement  may  be  made. 
In  none  of  these  collections  of  cases  did  there  appear  to  be 
any  definite  correlation  between  the  degree  of  the  atrophy  and 
the  special  form  of  the  disease,  and  in  the  special  discussions 
of  the  individual  groups  of  cases  it  has  been  stated  that  no 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      75 

correlation  between  the  degree  of  dementia  (paretic,  arterio- 
sclerotic, senile,  or  precox)  and  the  extent  or  the  degree  of  atrophy 
was  present. 

A  similar  statement  holds  true  for  the  probability  of  correla- 
tion between  degrees  of  atrophy  and  the  general  behavior  of 
the  cases  which  have  been  considered.  Such  behavior  as  the 
care  of  the  person  and  the  relations  of  the  individual  to  his 
environment  and  to  the  other  patients  did  not  vary  in  accordance 
with  the  location  or  the  amount  of  the  cerebral  changes. 

On  the  motor  side,  similarly,  we  find  no  definite  correlation 
existing.  In  the  dementia  precox  group  those  with  atrophies 
extending  beyond  the  frontal  regions  differed  in  no  respect  from 
those  in  which  the  atrophy  was  confined  to  the  less  extensive 
area.  The  paretics  with  simple  frontal  lesions  were  perhaps 
more  active  than  those  with  the  lesions  extending  over  the 
central  convolutions  and  into  the  parietal  lobe,  but  the  cases 
of  senile  dementia  and  those  with  arteriosclerosis  cerebralis 
were  about  equal  in  this  respect.  The  motor  phenomena  which 
are  found  associated  in  these  cases  with  atrophies  do  not  appear 
to  be  correlated  with  the  degree  of  the  atrophy.  In  none  of 
these  collections  of  cases  was  it  found  that  the  motor  phenomena 
differed  to  any  extent  when  the  degree  of  atrophy  was  great 
from  those  in  which  the  atrophy  was  slight. 

The  emotional  or  affective  states  of  these  patients  varied 
considerably.  No  one  fact  stands  out  particularly  to  indicate 
any  possible  relation  between  the  affective  states  of  these  pa- 
tients and  the  extent  or  the  degree  of  the  cerebral  atrophy,  and 
in  fact  in  this  case  the  conclusion  can  also  be  drawn  that  there 
is  no  correlation  of  this  character. 

The  variety  of  the  hallucinations  which  have  been  recorded 
and  the  fact  that  these  symptoms  were  not  uniformly  present 
in  those  with  similar  atrophies  does  not  indicate  any  definite 
relation  between  the  appearance  of  hallucinations  and  the 
atrophies  with  which  we  dealt.  It  would  appear  that  in 
the  dementia  precox  group  the  more  extensive  atrophies  were 
more  frequently  associated  with  the  presence  of  hallucinations, 


76  SHEPHERD  IVORY  FRANZ 

but  such  a  conclusion  can  not  be  made  regarding  the  groups  of 
paretic,  senile  and  arteriosclerotic  dements. 

Nor  do  the  delusions  appear  to  be  correlated  with  the  extent 
or  degree  of  atrophies.  Delusions  appear  to  be  as  relatively 
frequent  in  case  of  frontal  atrophy  as  in  those  cases  in  which 
the  atrophy  is  more  extensive,  and  in  this  connection  it  is  of 
interest  to  note  that  with  the  marked  changes  in  the  frontal 
lobes  which  have  been  noted  in  connection  with  a  number  of 
the  cases  delusions  were  not  always  found.  From  the  data 
which  were  available  to  him,  Southard  has  concluded  that  frontal 
lesions  are  more  frequently  accompanied  by  delusions,  but  in 
the  present  series  sufficient  cases  in  which  no  delusions  were 
present  have  been  observed,  in  which  frontal  atrophies  were 
present,  either  simple,  or  combined  with  those  of  the  central 
convolutions  and  at  times  with  those  of  the  parietal  region.  It 
is  worthy  of  note  that  di  the  dementia  precox  group  there 
were  three ;  of  the  paretics,  one ;  of  the  arteriosclerotics,  three ; 
and  of  the  senile,  five ;  a  total  of  twelve  cases,  in  which  no  evidences 
of  delusions  was  discovered,  although  in  all  df  these  cases  an 
atrophy  of  the  frontal  lobes  was  discovered  at  the  time  of  the 
autopsy.  As  a  possible  definite  relation  with  the  cerebral  lesions 
it  may  be  said  that  most  of  the  patients  exhibited  poor  memory 
and  poor  orientation.  On  the  other  hand,  the  accuracy  of 
memory  of  some  of  the  patients  was  remarkable  in  view  of 
the  degree  of  dementia  which  was  noted  to  be  present,  and  in 
some  of  the  cases  the  orientation  ability  was  also  remarkable  in 
view  of  the  extensive  cerebral  changes  which  were  found. 

Summing  up  this  portion  we  may  definitely  say  that  there 
has  been  discovered  in  the  present  collection  of  38  cases  no 
definite  relation  between  (A)  the  degree  of  mentality,  or  lack 
of  mentality,  the  character  of  the  disease,  the  motor  and  affective 
states,  the  presence  of  delusions  or  hallucinations,  memory  or 
orientation  ability,  and  (B)  the  degree  and  extent  of  the  cerebral 
atrophies. 


GENERAL  DISCUSSION 

On  the  assumption  that  similar  portions  of  the  brain  in  differ- 
ent individuals  have  like  functions,  we  should  expect  that  corre- 
sponding lesions  would  give  rise  to  similar  symptoms.  That, 
however,  the  symptoms  differ  even  though  the  lesions  be  similar 
is  shown  by  the  study  o'f  the  case  histories  which  have  been 
summarized  in  previous  sections.  In  addition,  it  requires  no 
extensive  acquaintance  with  the  clinical  contributions  of  neurol- 
ogists to  recognize  that  cerebral  lesions  other  than  atrophies 
do  not  always  result  in  similar  mental  abnormalities,  or  symp- 
toms. Nor  does  it  require  any  great  amount  of  critical  ability 
to  reach  the  conclusion  that  numerous  facts  which  have  been 
recorded  in  clinical  neurological  literature  do  not  always  warrant 
simple  explanations  of  the  relation  of  cerebral  activities  and 
and  mental  phenomena.  It  is  apparent  that  the  variations  in  the 
symptoms  which  accompany  similar  cerebral  lesions  in  different 
individuals  have  often  been  minimized  and  sometimes  disre- 
garded, perhaps  'for  the  sake  of  simplicity  of  explanation. 

In  some  few  cases,  on  the  other  hand,  the  variations  in  the 
results  of  physiological  investigations  of  stimulation  and  ex- 
tirpation and  the  differences  in  the  clinical  symptoms  accompany- 
ing similar  cerebral  lesions  have  also  led  to  numerous  polemics. 
Dissimilar  symptoms  have  been  shamefully  taken  from  their 
settings,  estimated  too  highly  and  extravagantly  emphasized  by 
those  who  controverted  the  quasi-phrenological  views  of  cerebral 
function. 

There  is,  however,  no  good  reason  either  for  disregarding 
the  dissimilarities  of  symptoms  accompanying  cerebral  lesions 
or  for  concluding  that  these  dissimilarities  demonstrate  that 
all  parts  of  the  brain  act  in  the  same  manner  and  that  there 
are  no  cerebral  "centers."  The  fact  of  dissimilarity  must  be 
accepted  and  brought  into  relation  with  the  other  facts  which 
are  known  regarding  cerebral  'function  and  control. 

It  has  already  been  pointed  out  that  in  physical  diseases  the 
symptoms  of  individuals  may  differ  to  a  considerable  extent, 
and  also  that  lesions  in  widely  separated  portions  of  the  brain 


7B  SHEPHERD  IVORY  FRANZ 

may  give  rise  to  different  symptoms  in  different  individuals. 
Many  neurologists  now  recognize  the  latter  fact,  and  von 
Monakow  in  particular  has  been  insisting  that  this  fact  is  of 
primary  importance  for  deducing  the  functions  and  functional 
connections  of  the  cerebrum.  The  similarity  of  symptoms  ac- 
companying different  lesions  is  readily  understood  if  v^t  conceive 
of  the  nervous  system,  and  especially  the  cerebrum,  as  a  collec- 
tion of  cells  w^ith  connections,  the  function  of  which  is  fixed 
largely  because  of  the  intercommunicating  connections.  The 
individual  cell  has  its  own  function,  but  in  the  production  or 
control  of  any  of  the  cerebrally  produced  or  controlled  processes 
in  other  parts  of  the  body,  or  of  mental  states,  it  is  the  serial 
or  grouped  activities  of  nerve  cells  which  must  be  dealt  with. 
When  this  view  is  taken  it  becomes  clear  why  dissimilar  lesions 
may  produce  similar  symptoms.  A  break  at  any  part  of  the 
chain  will  prevent  the  normal  function,  which  is  serial. 

It  is  now  recognized  that  widely  separated  areas  are  always 
involved  even  when  only  a  very  small  portion  of  the  cerebral 
cortex  is  injured  or  destroyed.  The  destruction  of  some  por- 
tions may  immediately  produce  perfectly  obvious  defects  or  ex- 
aggerations of  normal  behavior,  while  the  destruction  of  other 
portions  may  give  rise  to  effects  which  are  not  immediate  or 
obvious.  The  effects  of  the  latter  lesions  are  sometimes  to  be 
discovered  only  indirectly  and  at  other  times  they  are,  as  von 
Monakow  points  out,  of  a  "latent  nature  and  only  become  mani- 
fest when  there  is  added  to  the  primary  operation  {i.e.,  a  lesion) 
a  second  operation  upon,  or  a  pathological  process  in,  another 
region  of  the  cortex."^ 

The  present  series  of  facts  are,  however,  different  from  those 
with  which  von  Monakow  and  others  have  dealt.  They  are 
the  reverse  conditions,  and  they  are  not  readily  understandable 
on  the  hypothesis  which  von  Monakow  has  set  forth  to. explain 
the  similarity  of  symptoms  with  dissimilar  lesions.  In  connec- 
tion with  these  studies  of  *frontal  and  anterior  atrophies  it 
should  be  pointed  out  that   dissimilarities   of   symptoms   from 

'  Monakow,  C  von.  Theoretische  Betrachtungen  iiber  die  Lokalisation  im 
Zentralnervensystem,  insbesonder  im  Grosshirn.  Ergebnisse  der  Physiol.^ 
191 3.  13.  206-278. 


SYMPTOMATOLOGICAL  DIFFERENCES  IN  THE  INSANE      79 

frontal  lesions  have  not  infrequently  been  the  cause  of  much 
discussion  and  recrimination.  Thus,  the  clinical  findings  which 
have  been  recorded  at  different  times  by  different  investigators 
whose  material  (patients)  was  not  exactly  the  same  have  given 
rise  to  the  hypothesis  that  the  frontal  lobes  are  (i)  intellectual 
centers,  (2)  centers  for  emotional  states,  (3)  centers  for  in- 
hibition, and  (4)  motor  centers.  Without  attempting  at  the 
present  time  to  advance  a  more  general  hypothesis  than  those 
already  suggested,  it  may  be  said  that  the  clinical  facts  are  not 
mutually  exclusive  and  that  all  can  be  brought  together  under 
one  heading  which  gives  a  suggestion  for  the  explanation  of  the 
functions  of  the  frontal  lobes. 

Facts  of  an  experimental  nature  are  also  at  hand  to  show 
that  the  definiteness  of  control  by  the  motor  (precentral)  cortex 
is  not  as  great  as  that  which  is  usually  assumed  to  be  the  case. 
These  will  be  dealt  with  in  the  second  part  of  this  monograph.  All 
of  the  facts  indicate  that  we  must  conclude  that  the  action  of  the 
cerebrum  is  a  diffuse  activity,  and  an  activity  which  varies  from 
individual  to  individual,  and  in  the  same  individual  from  time 
to  time.  A  full  discussion  of  this  hypothesis  will  appear  in 
connection  with  the  study  of  the  variability  of  control  from  the 
motor  cortex.  At  the  present  time  it  may  be  mentioned  that  it 
seems  most  satisfactory  to  consider  the  cerebrum  as  a  labile 
organ  or,  in  other  words,  as  a  series  of  cells  with  numerous 
possibilities  of  connections.  The  number  of  connections  makes 
possible  a  variety  of  activities,  since  at  one  time  a  cell  may  act 
through  its  main  axonal  connection  upon  a  second  cell,  and  at 
another  time  through  its  collateral  connections  it  may  act  upon 
a  third  or  fourth  cell.  Probably  the  cerebral  cells  do  not  always 
discharge,  or  influence  other  cells,  in  the  same  manner.  We 
should,  therefore,  not  hold  to  a  belief  in  a  definiteness  and 
simplicity  of  physiological  connections,  but  rather  to  a  manifold- 
ness  of  connections,  any  one  or  more  of  which  may  be  used  or 
not  used  at  one  time.  The  use,  non-use,  or  disuse  of  any  one 
of  the  possible  paths  at  different  times  will  produce  differences 
in  behavior,  and  similar  lesions  of  cells  may,  therefore  produce 
different  symptoms  in  accordance  with  the  normal  (to  the  in- 
dividual) connections  which  have  thus  been  interfered  with. 


II 

VARIATIONS  IN  DISTRIBUTION  OF  THE 
MOTOR  CENTERS 

INTRODUCTION 

The  earliest  positive  results  of  the  electrical  stimulation  of 
the  cortex  were  obtained  by  Fritsch  and  Hitzig,  and  at  that 
time  and  for  a  number  of  years  the  movements  obtained  on 
stimulation  of  the  cerebral  cortex  were  described  in  terms  such 
as  to  suggest  that  the  resulting  movements  were  definite  move- 
ments of  individual  muscles.  Subsequently  attempts  were  made 
to  determine  the  cortical  localization  or  representation  of  in- 
dividual muscles  or  muscle  groups,  but  it  was  amply  demon- 
strated by  more  recent  experiments  (especially  those  of 
Sherrington  and  Griinbaum  (6)  that  all  the  movements  which 
result  from  cortical  stimulation  are  complex  movements.  These 
are  ''movements"  in  a  particular  sense  of  the  word  and  not 
simply  contractions  of  muscles.  They  are  movements  which 
are  best  described  as  behavior  phenomena,  not  only  movements 
of  flexion  but  movements  of  grasping,  not  simply  extension 
movements  but  movements  of  repulsion  or  thrusting  away.  In 
many  cases  the  complex  activities  of  the  associated  muscular 
contractions  can  best,  and  at  times  can  only,  be  described  in 
terms  of  such  behavior  activities. 

From  time  to  time  in  attempting  to  demonstrate  the  motor 
control  by  the  cortex  by  stimulating  the  so-called  motor  centers 
difficulty  was  experienced  by  me  with  some  animals  in  obtaining 
special  reactions  of  parts  which  appeared  to  be  readily  obtainable 
in  other  animals.^  These  variations  in  the  stimulability  or  in 
the  control   from  the  cortex  were  at  first,  on  account  of  the 

^  Compare  also  Sherrington's  remark :  "In  the  cat  it  is  in  ray  experience 
quite  infrequent  to  obtain  primary  extension  of  the  crossed  elbow  from  the 
cortex.  Flexion  is  readily  and  regularly  obtained."  Integrative  Action  of 
the  Nervous  System,  1906,  page  293. 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS       8i 

definiteness  with  which  most  previous  results  have  usually  been 
described,  believed  by  me  to  be  due  to  defects  in  technic  or  to 
variations  in  the  excitability  of  different  cortical  regions  in  dif- 
ferent animals  under  anaesthesia.  A  careful  examination  of 
the  literature  devoted  to  the  experimental  investigation  of  the 
motor  cortex  in  animals  indicated,  however,  that  notwithstanding 
the  supposed  definiteness  there  was  considerable  variation  in 
the  location  of  special  areas  in  different  animals.  This  variation 
appeared  to  depend,  to  some  extent  at  least,  upon  the  varying 
configurations  of  the  fissures  and  consequently  the  varying  posi- 
tions of  the  collections  of  cells  governing  particular  movements. 
On  the  other  hand,  it  also  appeared  possible  that  some  of  these 
variations  might  be  variations  of  a  primary  nature,  i.e.,  not 
due  to  the  adventitious  condition  of  anaesthesia  or  other  similar 
circumstances.  In  fact,  the  careful  examination  of  published 
work  on  the  motor  cortex,  especially  that  of  the  Vogts  (H), 
shows  that  the  location  of  the  individual  cerebral  areas  controlling 
certain  of  the  small  bodily  segments  is  not  as  anatomically 
(spatially)  definite  as  has  been  supposed.  Such  as  least  was  the 
suggestion  that  was  received  when  the  results  of  previous  in- 
vestigations were  compared.  Accurate  determinations  of  the 
variations  of  previous  investigations  were  not  found  to  be  prac- 
tical, both  on  account  of  the  differences  in  method  that  individual 
investigations  had  employed  and  their  methods  of  recording 
results  and  also  on  account  of  the  different  species  of  animals 
on  which  the  tests  were  made. 

Because  of  these  considerations,  it  was  thought  advisable  to 
attempt  comparisons  of  the  results  of  the  stimulation  of  the 
brains  of  a  number  of  animals  of  the  same  species  in  order  to 
determine  how  much,  if  any,  variation  there  is  in  the  relation 
of  parts  of  the  precentral  cortex  to  the  control  of  different  bodily 
segments.  It  appeared  possible  that  in  this  area  of  the  brain 
there  are  variations  of  an  individual  nature,  not  explainable  on 
the  ground  of  variations  in  fissural  configurations.  The  animals 
chosen  for  the  present  investigation  were  monkeys,  macacus 
rhesus,  five  of  which  gave  results  of  value. 


METHODS 

An  animal  was  driven  from  its  cage  into  a  large  burlap  sack 
and  completely  anaesthetized.  It  was  then  transferred  to  the 
operating  board  and  kept  under  the  anaesthetic  during  the  whole 
period  of  the  experiment.  The  A.C.E.  mixture  was  used  in 
all  of  the  experiments.  At  the  time  the  movements  of  the 
animal  were  to  be  determined  all  the  limbs  were  untied,  but 
the  head  was  kept  steadied  in  a  head-holder  so  that  head  move- 
ments might  not  take  place  or  be  minimized.  The  present  series 
of  tests  were  intended  to  deal  largely  with  the  relation  of  the 
cerebrum  to  the  leg  and  arm  movements,  and  the  head  move- 
ments were  disregarded  except  when  the  latter  were  associated 
with  movements  of  the  other  segments.  Since,  however,  the 
head  was  kept  fairly  rigid,  most  of  the  head  movements  were 
prevented  and  with  the  exception  of  a  few  have  not  been  re- 
corded. This  procedure  of  steadying  the  head  were  also  used 
for  another  reason,  viz.,  to  prevent  possible  injuries  to  the 
brain  when  the  head  moved  at  the  time  the  stimulating  electrodes 
were  applied.  Except  by  having  the  electrodes  attached  firmly  to 
the  skull  so  that  they  move  with  it,  it  is  not  always  possible  to 
avoid  accidental  injuries  of  this  nature,  but  in  the  present  series 
such  avoidable  injuries_J;Q_.the-  brain  were  prevented  by  keeping 
the  head  steadied. 

A  one-half  inch  trephine  was  used  to  cut  through  the  skull 
to  such  a  point  that  the  button  of  bone  could  be  readily  removed. 
The  trephine  was  not  permitted  to  cut  entirely  through  the  inner 
table  of  the  skull  on  account  of  the  possibility  that  the  trephine 
teeth  might  also  cut  through  the  dura  mater  and  thus  injure 
the  brain.  In  this  way  also  injury  to  the  cerebral  cortex  was 
prevented  as  much  as  possible,  and  in  no  case,  as  far  as  could 
be  determined  by  an  inspection  of  the  brain  through  a  magnify- 
ing glass  was  any  gross  injury  produced.  After  the  skull  open- 
ings had  been  made  in  this  manner  they  were  enlarged  in  different 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS       83 

directions  by  bone  forceps  in  order  to  uncover  a  large  portion 
of  the  frontal  area,  all  of  the  so-called  precentral  region  and 
a  considerable  part  of  the  postcentral  cortex.  Bleeding  from 
the  diploe  was  checked  by  the  application  of  bone  wax.  When 
the  large  openings  on  both  sides  of  the  skull  had  been  made 
the  bridge  of  bone  which  covered  the  longitudinal  fissure  was 
cut  through  after  ligatures  had  been  placed  at  both  extremities 
of  the  bridge  in  order  to  prevent  bleeding  from  the  longitudinal 
sinus.  In  previous  tests  bleeding  from  this  source  was  found 
to  be  very  great  and  in  one  of  the  animals  used  in  the  present 
series  even  the  precautions  of  ligating  the  longitudinal  sinus 
which  were  taken  did  not  prevent  death  from  hemorrhage.  The 
dura  was  next  cut  and  this  was  partly  reflected  and  partly  cut 
away  so  as  to  leave  the  portion  of  the  cortex  which  was  to  be 
stimulated  bare. 

The  part  of  the  brain  which  was  not  at  the  time  being  sub- 
jected to  stimulation  exploration  was  covered  with  thin  rubber 
tissue  which  had  been  wet  with  warm  normal  salt  solution  and 
all  was  covered  with  a  large  sponge  of  cotton  which  had  also 
been  wet  and  warmed  in  the  same  solution.  Sufficient  time 
elapsed  between  the  individual  stimuli  to  permit  the  recording 
of  results  and  this  also  rested  the  brain  tissue.  After  a  series 
of  half  a  dozen  or  more  stimulations  the  part  of  the  brain  which 
was  being  used  was  covered  by  the  rubber  tissue  and  the  sponge, 
and  the  brain  was  permitted  to  rest  for  a  longer  period,  five 
to  ten  minutes.  In  this  way  the  brain  was  protected  at  times 
when  the  tests  were  not  being  made.  In  this  way  also  drying 
could  not  take  place,  and  little,  if  any,  of  the  anaesthetic  gases 
escaping  into  the  room  could  act  directly  upon  the  cerebral  cells. 
At  the  same  time  the  use  of  the  rubber  tissue  prevented  too  much 
moistening  of  the  brain  substance,  for  it  should  be  recognized 
that  there  is  a  possibility  that  the  use  of  too  much  of  the 
normal  salt  solution  may,  by  osmosis,  sufficiently  change  the 
chemical  character  of  the  cortical  cells  to  produce  alterations 
in  their  irritability.  The  duration  of  the  tests  on  one  side  of 
the  brain  was  usually  about  three  hours.  In  certain  cases  where 
the  number  of  stimulable  points  was  small  this  time  was  short- 


84  SHEPHERD  IVORY  FRANZ 

ened  and  on  one  animal  in  which  the  number  of  points  was 
large,  this  time  was  much  increased.  In  addition  to  the  careful 
administration  of  the  anaesthetic,  the  precautions  to  avoid 
"fatigue"  and  those  to  prevent  osmotic  changes  from  the  ap- 
plication of  the  moistening  solutions  tended  to  keep  the  cortical 
irritability  at  approximately  constant  level,  and  any  experiment, 
if  it  had  appeared  necessary  or  advisable,  might  have  been  carried 
on   for  a  greater  length  of  time. 

It  was  not  found  difficult  to  keep  the  animal  sufficiently  under 
the  effect  of  the  anaesthetic  during  the  whole  period  of  time, 
for  care  was  taken  that  the  quantity  should  be  sufficient  to 
prevent  any  voluntary  movements  which  might  mask  or  inter- 
fere with  the  movements  which  were  produced  by  the  electrical 
stimulations,  but  at  the  same  time  the  anaesthetic  was  not  pushed 
to  such  a  degree  as  would  be  necessary  in  experiments  in  which 
complete  relaxation  of  the  involuntary  muscles  is  desired.  In 
no  case  was  the  anaesthetic  deep  enough  to  produce  a  relaxation 
of  the  sphincters,  but  by  continuous  careful  application  all  of 
the  voluntary  movements  were  prevented,  even  at  the  times 
when  cutting  and  trephining  were  performed. 

The  cortex  was  stimulated  by  the  bipolar  method,  the  in- 
duction coil  being  a  standard  Helmholtz  apparatus.  The 
platinum  points  were  separated  by  approximately  one-quarter 
of  a  millimeter  and  each  of  the  points  was  approximately  of 
the  same  size.  The  distance,  therefore,  between  the  centers  of 
the  points  was  approximately  one-half  of  a  millimeter.  The 
electrode  points  were  applied  to  a  special  portion  of  the  cortex 
and  after  the  stimulation  and  the  resulting  reaction  (when  any 
occurred)  they  were  removed.  The  secondary  coil  of  the  in- 
ductorium  was  arranged  at  the  beginning  of  a  series  of  tests 
on  an  animal  at  such  a  point  as  to  give  a  supra-minimal  stimula- 
tion. It  was  kept  at  this  point  throughout  the  series  of  tests 
on  that  animal,  with  the  exception  that  when  with  this  strength 
of  current  an  apparently  non-stimulable  area  was  found,  the 
strength  of  the  stimulus  was  increased  to  determine  whether  the 
failure  of  reaction  was  due  to  a  normal  non-stimulable  character 
of  the  special  area  or  to  a  decrease  of  irritability.    It  was  found 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS       85 

that  the  increased  stimulus  seldom  gave  rise  to  movements,  and 
when  failures  with  the  increased  stimulus  were  encountered 
it  was  concluded  that  these  areas  were  normally  non-stimulable. 
It  is  likely  that  further  increases  in  the  strength  of  the  stimuli 
might  have  resulted  in  reactions,  but  with  greater  strengths  of 
stimuli  the  possibility  of  "spreading"  is  greater  and  the  results 
would  have  been  open  to  serious  objection  on  this  score. 

The  stimulations  were  usually  first  begun  at  the  upper  portion 
of  the  precentral  area  where  the  motor  cortex  dip  downwards 
into  the  longitudinal  fissure.  Eight  or  ten  stimuli  were  given  in  a 
regular  order  as  close  as  possible  to  the  central  fissure,  and  ex- 
tending serially  towards  the  fissure  of  Sylvius,  the  stimulated 
points  being  approximately  one  millimeter  apart.  Another  series 
was  begun  at  the  extreme  upper  limit  of  the  precentral  area  and 
the  stimuli  were  carried  downwards  in  a  line  which  was  approxi- 
mately one  millimeter  in  front  of  the  line  along  which  the  pre- 
vious series  of  stimuli  had  been  given.  Third,  fourth,  etc.,  series 
were  made  in  the  same  manner,  each  extending  one  millimeter 
anteriorly  to  the  previous  one.  In  this  way  the  experiment  was 
carried  on  until  in  passing  forwards  a  line  or  series  of  stimuli 
had  been  given  which  produced  no  observable  reactions.  In  cer- 
tain animals,  on  account  of  the  presence  of  blood  vessels  and 
extra  fissures,  lines  in  which  no  stimuli  were  given  were  present. 
In  most  cases,  however,  the  blood  vessels  which  were  encountered 
were  not  much  greater  than  one  millimeter  in  diameter  and  thus 
the  general  experimental  relationships  were  not  markedly  dis- 
turbed. After  such  an  area,  about  ten  millimeters  in  length  and 
in  width  to  correspond  to  the  stimulable  zone,  had  been  carefully 
examined,  similar  series  were  made  in  the  area  immediately  below 
(towards  the  fissure  of  Sylvius).  In  this  manner  the  whole  of 
the  superficial  precentral  cortex  extending  from  the  longitudinal 
fissure  downwards  as  far  as  the  head  area  was  carefully  mapped 
out. 

After  every  second  stimulation  a  small  portion  of  a  mixture 
which  was  composed  of  vaseline  and  analine-black  was  applied 
to  the  point  which  had  been  previously  stimulated.  This  mix- 
ture was  viscid,  and  sufficient  could  be  taken  upon  the  point  of 


86  SHEPHERD  IVORY  FRANZ 

a  sharp  probe  which,  when  lightly  touched  to  the  brain,  left  a 
speck  of  this  "paint"  upon  the  brain  surface.  In  some  cases  the 
individual  points  did  not  stand  out  by  this  method  as  clearly 
as  was  desired,  but  in  many  of  the  experiments  the  points  of 
application  of  the  analine-black  mixture  could  be  correctly  de- 
termined and  the  relative  locations  of  the  individual  points  of 
stimulation  were  therefore  accurately  given  on  the  cortex.  The 
application  of  the  wet  rubber  tissue  and  sponge  after  a  series  of 
tests  tended  to  obliterate  the  marks  which  were  made,  but  the 
pia  mater  (and  the  brain?)  was  sufficiently  stained  in  many  cases 
so  that  the  individual  points  were  to  be  seen  when  the  brain  was 
examined  with  a  magnifier.  The  stained  points  were  later  com- 
pared with  the  photographs  and  with  the  diagrams  which  were 
used. 

At  the  time  of  the  performance  of  the  experiment  a  rough 
sketch  (with  a  magnification  of  about  ten  diameters)  of  the 
general  appearance  of  the  precentral  and  postcentral  regions  of 
the  hemispheres  was  made.  On  this  sketch  the  longitudinal  fis- 
sures, the  central  fissures,  subsidiary  fissures,  and  the  blood 
vessels  were  noted.  Following  each  test  the  location  of  the  stimu- 
lated point  was  marked  on  the  sketch  so  that  this  could  be  com- 
pared with  the  location  of  the  stain  which  had  been  applied  to 
the  brain.  The  serial  numbers  of  the  tests  were  noted  on  the 
sketch  in  approximately  correct  relations.  These  sketches  were 
subsequently  used  for  the  identification  of  the  stimulated  points. 
After  the  removal  of  the  brain  and  its  hardening  in  formalin 
(lo  per  cent)  the  area  which  was  found  to  be  stimulable  was 
again  sketched  by  placing  over  the  cortex  a  piece  of  transparent 
paper  which  was  pressed  down  tightly  and  which  was  marked 
to  show  all  of  the  points  of  interest  (fissures,  blood  vessels,  ex- 
tent  of  the  stained  zone,  etc.)  in  that  particular  area.  These 
diagrams  were  then  placed  in  the  Leitz  projection  apparatus  and 
drawings  were  made  of  the  results  with  a  magnification  of  ten 
diameters.  On  the  drawings  which  accompany  the  present  work 
corrections  have  been  made  in  the  diagrams  by  comparisons  with 
actual  brain  pictures  (photographs),  so  that  the  diagrams  which 
are  here  represented  are  combinations  of  the  sketches  taken  at 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS       87 

the  time  of  the  performance  of  the  experiments  with  the  actual 
pictures  of  the  brains.  At  the  time  the  brain  was  photographed 
a  two  milhmeter  scale  was  placed  along  the  central  fissure  and 
photographed  with  the  brain.  The  photographs  were  later  mag- 
nified uniformly  at  10  diameters,  each  millimeter  on  the  photo- 
graphed scale  corresponding  to  10  on  the  diagram,  and 
drawings  made  of  all  the  important  landmarks.^ 

On  these  drawings  the  points  of  stimulation  were  noted  and  the 
numbers  corresponding  to  the  serial  tests  were  recorded.  Since 
the  diagrams  were  drawn  to  scale,  the  results  which  are  recorded 
in  them  may  be  considered  to  represent  fairly  accurately  the  ex- 
tents of  the  stimulable  motor  areas  in  the  individual  hemispheres 
of  the  five  monkeys  which  were  used.  It  will  be  noted  that  these 
areas  differ  considerably  in  absolute  sizes,  monkey  2  having  a 
more  extensive  responsive  area  than  any  of  the  other  animals, 
monkey  4  having  the  least  extensive  stimulable  motor  area. 

At  the  time  the  experiments  were  performed  there  were  usually 
four  observers.  The  chief  duty  of  one  was  the  manipulation  of 
the  electrodes.  This  observer  also  directed  the  experiment,  noting 
on  the  rough  sketch  the  points  which  had  been  stimulated  and 

^  Since  there  is  a  considerable  curvature  of  the  brain  from  the  longitudinal 
fissure  towards  the  temporal  areas  (of  special  interest  in  this  connection 
being  the  curvature  in  the  region  of  the  central  fissure)  the  photographs 
showed  considerable  spatial  distortions  of  the  sides  of  the  brain.  In  the 
projection  of  the  photographs  only  the  two  millimeter  divisions  on  the 
relatively  flat  superior  surface  of  the  brain  could  be  made  to  correspond  with 
the  twenty  millimeter  divisions  of  the  projection  screen.  The  landmarks 
('fissures,  blood  vessels,  etc.)  and  the  scale  divisions  were  recorded  as  they 
were  magnified.  These  drawings  were  then  dealt  with  as  if  the  curved 
surface  was  simple,  i.e.,  like  that  of  a  cylinder,  and  the  proper  geometrical 
projections  were  made  to  bring  about  the  uniform  distribution  of  the  area. 
It  is  realized  that  for  the  most  accurate  representation  we  should  deal  not 
only  with  the  superior-inferior  curvature  but  with  the  fronto-posterior  cur- 
vature as  well.  The  latter  curvature  in  the  region  of  the  central  fissure  is 
however,  slight  as  compared  with  the  superior-inferior  curvature  and  has 
been  disregarded.  The  error  of  recording  due  to  this  method  is,  I  am 
advised,  probably  not  as  large  as  5  per  cent.  Since  also  these  drawings 
were  later  compared  with  the  brains,  with  the  enlarged  diagrams  on  trans- 
parent paper,  and  with  the  original  sketches,  the  error  is  doubtless  much  less 
than  this  amount.  It  is  presumed,  however,  that  the  error  is  about  equal 
for  all  brains  and  the  results  are,  therefore,  comparable. 


88  SHEPHERD  IVORY  FRANZ 

applying  to  the  cortex  the  analine-black  mixture.  A  second  ob- 
server took  charge  of  the  anaesthetic,  his  attention  being  directed 
principally  to  the  matter  of  keeping  the  animal  under  good  anaes- 
thetic control,  but  he  assisted  at  times  in  the  observation  of  the 
activities  of  the  animal  which  accompanied  the  stimulations.  A 
third  observer  recorded  the  results  of  the  individual  stimuli  on 
sheets  of  paper,  noting  at  the  same  time  the  serial  numbers  and  the 
times  of  the  stimulations.  This  observer  also  cooperated  with 
the  fourth  one  in  noting  the  character  of  the  movements.  The 
fourth  observer  had  as  his  sole  duty  the  observation  of  the  move- 
ments which  resulted  from  the  stimuli  and  the  description  of 
the  movement  so  that  they  might  be  recorded.  As  has  already 
been  said,  the  anaesthetist  also  occasionally  helped  to  observe 
the  movements.  Only  when  the  two  or  three  special  observers  of 
the  reactions  (movements)  were  satisfied  regarding  the  charac- 
ters of  the  reactions  were  they  recorded.  If  there  was  a  doubt  of 
a  more  or  less  serious  nature  regarding  the  combination  of  move- 
ments which  was  produced  the  particular  point  was  subjected  to 
a  second  stimulation  at  a  later  time. 

Following  the  determination  of  all  the  available  jx)ints  in  the 
leg  and  arm  areas  the  animal  was  killed  by  an  overdose  of  chloro- 
form. The  brains  were  hardened  in  formalin  and  preserved  for 
future  study.  The  extent  of  the  stimulable  areas  was  determined 
in  the  manner  described  above  after  the  brain  had  been  thoroughly 
hardened.  The  location  of  the  points  for  the  individual  segments 
or  parts  of  segments  was  also  made  in  the  manner  similar  to  that 
described  above,  and  are  here  reproduced  in  the  diagrams. 

The  serial  numbers  of  the  original  individual  tests  have  not  been 
included  in  the  present  accounts,  for  to  bring  about  an  areal  cor- 
respondence of  the  allied  areas  in  all  animals  the  serial  numbers 
in  the  individual  experiments  were  not  available.  This  was  due 
to  the  fact  that  variations  in  the  conduct  of  the  experiments,  i.e., 
the  varying  location  of  the  different  fissures  and  different  blood 
vessels,  etc.,  were  present  to  alter  the  constant  serial  character  of 
the  experiments  in  the  different  hemispheres.'     Furthermore,  in 

*That  is,  test  lo,  or  test  36,  or  test  72,  did  not  always  bear  the  same  rela- 
tion to  the  well  known  anatomical  landmarks  in  all  hemispheres. 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS       89 

the  illustrations  which  are  given  later  the  areas  have  been,  for 
the  purpose  of  comparison,  divided  into  special  zones,  although  it 
should  be  understood  that  these  zones  by  the  methods  used,  are 
only  approximately  determinable  for  any  one  hemisphere.'*  At 
the  same  time,  since  the  individual  areas  differ  widely  in  extent,  it 
should  be  noted  that  spatial  comparisons  of  two  or  more  hemi- 
spheres can  be  only  approximate. 

In  the  present  work  as  has  been  noted  above,  attention  was 
directed  to  those  areas  which  are  concerned  with  the  movements 
of  the  leg  (including  the  thigh,  lower  leg,  foot  and  toes)  and 
with  the  arm  (including  the  shoulder,  forearm,  hand  and  fin- 
gers). The  associated  movements  of  the  head  which  were  occa- 
sionally met  with  in  the  stimulation  of  the  arm  area  will  not  be 
detailed  in  the  present  paper.  The  present  paper,  therefore,  deals 
primarily  with  the  areas  concerned  with  the  anterior  and  posterior 
limbs  and  occasionally  with  the  associated  movements  of  the  tail 
The  results  of  the  experiments  are  given  in  four  divisions  as  fol- 
lows :  ( I )  the  total  extents  of  the  stimula.ble  areas  for  the  arm  and 
leg;  (2)  a  comparison  of  the  distribution  for  the  leg  and  for  the 
arm;  (3)  a  comparison  of  the  distributions  of  the  areas  for  the 
smaller  segments  (fingers,  hand,  lower  arm,  upper  arm,  toes,  foot, 
lower  leg  and  thigh)  ;  and  (4)  the  anomalous  distribution  of  the 
stimulable  areas,  namely  (a)  those  areas  which  gave  leg  move- 
ments when  the  surrounding  areas  gave  arm  movements,  (b) 
those  areas  which  gave  arm  movements  when  the  surrounding 
areas  gave  leg  movements,  and  (c)  the  nonstimulable  (or  rela- 
tively non-stimulable)  areas  which  were  surrounded  by  readily 
stimulable  areas. 

Several  possible  objections  may  be  urged  against  considering  the 
diagrams  to  include  all  of  the  motor  responsive  areas  for  the  arm 

*  In  other  words,  in  the  diagrams  each  point  of  experimental  stimulation  is 
represented  by  an  area.  Since  the  stimulated  points  were  one  millimeter 
apart,  the  square  millimeter  surrounding  a  point  was  considered  to  correspond 
with  the  point.  A  micrometric  method  of  moving  the  stimulating  electrodes 
or  the  use  of  one  pole,  by  the  unipolar  and  monopolar  methods,  would  have 
permitted  the  stimulation  of  more  points,  and  the  diagrammatic  representa- 
tions would  have  been  nearer  the  actual  conditions.  Since,  however,  we  deal 
with  comparative  results  with  the  same  method  on  all  animals  the  slight 
variations  due  to  method  can  be  largely  disregarded. 


90  SHEPHERD  IVORY  FRANZ 

and  leg.  One  possible  objection  is  that  the  stimuli  may  not  have 
been  sufficiently  strong  to  bring  about  responses  in  the  outlying 
portions  of  the  areas,  and  that  in  any  one  of  the  monkeys  the 
total  area  which  was  found  stimulable  may  be  only  the  combin- 
ation of  more  readily  stimulated  points.  Such  an  objection  would 
be  valid  were  it  not  that  in  those  cases  in  which  the  extent  of  the 
area  seemed  to  be  slight,  additional  slightly  stronger  stimuli  were 
given  in  order  that  there  should  be  a  reasonable  certainty  regard- 
ing the  outer  limits.  When  these  increased  stimuli  failed  to 
produce  a  response  it  was  deemed  that  the  limits  of  the  normally 
excitable  area  had  been  reached.  The  use  of  much  stronger 
stimuli  may  be  objected  to  in  this  connection,  since  the  stronger 
stimuli  tend  to  spread  to  a  great  degree  and,  therefore,  to  have 
a  more  widespread  physiological  effect  than  the  weaker  stimuli. 
Since  the  precautions  were  taken  however,  as  a  check  and  nega- 
tive results  were  obtained,  the  negative  results  may  be  considered 
to  be  confirmations  of  the  limitation  of  what  we  may  call  the 
"immediately"  excitable  zone. 

Another  objection  which  may  be  urged  against  considering 
these  results  of  absolute  (rather  than  relative)  value  is  that  no  ac- 
count has  been  taken  of  the  stimulable  portions  of  the  cortex 
which  are  included  within  the  central  and  within  the  subsidiary 
fissures.  This  objection  is  in  most  respects  weighty  for  it  is 
realized  that  there  may  be  a  possible  inverse  relation  between  the 
amount  of  the  stimulable  cortex  on  the  convexity  or  surface  of 
the  brain  and  that  to  be  found  lying  within  the  fissures.  It  may 
be  admitted  at  the  outset  that  in  the  present  work  no  measure- 
ments (stimulation  or  otherwise)  have  been  made  of  the  quantity 
or  extent  of  the  motor  cortex  which  dips  down  into  the  central 
fissures.  It  may  also  be  admitted  that  some  of  the  variations 
which  have  been  discovered  by  the  present  methods  may  be  varia- 
tions of  an  anatomical  nature  as  described  above  (inverse  rela- 
tion of  surface  and  fissure  extents).  It  is  not  true,  however,  that 
all  the  variations  can  be  explained  in  this  manner.  Some  varia- 
tions that  will  be  noted  later,  especially  those  of  the  distribution 
of  the  areas  for  the  individual  segments  cannot  be  explained 
in  this  manner.    On  account  of  the  possible  objection  to  certain  of 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS       91 

the  results  it  may  be  mentioned  that  the  correlation  of  the  extent 
of  the  motor  cortex  anterior  to  and  that  within  the  fissure  of 
Rolando  is  a  problem  which  I  hope  to  be  able  to  deal  with  in  a 
subsequent  publication. 

A  third  objection  is  that  the  motor  areas  dipping  downward 
into  the  longitudinal  sulcus  have  not  been  considered.  In  most 
of  the  hemispheres  this  objection  does  not  hold  since  the  areas 
within  the  longitudinal  sulcus  were  investigated  and  the  results 
recorded.  In  the  case  of  the  left  hemisphere  of  monkey  3,  how- 
ever, not  even  all  the  convexity  surface  was  investigated,  as  will 
be  noted  below. 


EXPERIMENTAL  RESULTS 

Before  proceeding  to  the  accounts  of  the  results  of  the  experi- 
ments it  appears  desirable  to  present  a  series  of  figures  which 
describe  numerically  the  brains  of  the  animals  on  which  the 
experiments  were  performed.  These  figures  are  given  for  the 
reason  that  the  areal  variations  of  the  stimulable  zones  might 
have  correlations  with  the  brain  sizes  or  brain  weights.  Because 
of  this  there  are  given  various  linear  measurements  and  diameters 
since  the  selection  and  use  of  one  measure  for  possible  correla- 
tion might  be  considered  to  be  too  arbitrary.  The  measurements 
were  made  approximately  one  year  subsequent  to  the  performance 
of  the  tests,  after  the  brains  had  been  continuously  in  formalin 
(lo  per  cent).  All  measures  were  taken  in  the  nearest  half 
millimeter  or  nearest  half  gram. 

The  diameter  measurements  which  are  recorded  were  made 
with  slide  calipers.  The  total  length  was  taken  as  the  longest 
diameter  between  the  frontal  and  occipital  poles.  The  total 
width  is  the  greatest  side  to  side  diameter.  This  is  sometimes 
found  caudad  to  the  position  of  a  plane  from  the  upper  portion 
of  the  central  fissure  perpendicular  to  the  longitudinal  sulcus. 
Since  the  measurements  just  noted  can  give  only  a  general  view 
of  the  brain  as  a  whole  it  was  also  thought  best  to  take  data 
referring  to  the  frontal  (anterior  to  the  central  fissure)  portions 
of  the  brain.  The  frontal  width  was  taken  on  each  side  from 
the  longitudinal  sulcus  to  the  side  of  the  bzrain,  on  a  plane 
passing  through  the  central  fissure  approximately  one-half  of 
the  distance  from  the  longitudinal  sulcus  to  the  end  of  the  central 
fissure  near  the  fissure  of  Sylvius.  The  frontal  length  is  also 
given  for  the  two  sides  separately.  It  is  the  distance  between 
the  anterior  tip  of  the  brain  and  a  plane  passing  through  the 
brain  and  beginning  at  the  origin  of  the  central  fissure  near  the 
longitudinal  sulcus  and  perpendicular  to  the  latter.  The  length 
of  the  central  fissure  could  not  be  measured  as  accurately  as  the 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS       93 

lengths  already  mentioned.  A  narrow  pliable  but  non-stretchable 
tape  was  laid  along  the  fissure  beginning  at  either  its  superior  or 
inferior  end  and  passing  over  its  various  curves  as  well  as 
possible.  The  weights  of  the  brain  were  determined  to  the  nearest 
half  gram,  the  weights  being  of  the  cerebrum  alone.  The 
medulla,  cerebellum  and  spinal  cords  had  not  been  preserved. 
Three  measurements  of  each  kind  were  made;  the  results  were 
averaged  and  in  the  table  the  averages  are  noted  to  the  nearest 
half  millimeter  or  half  gram. 

The  brain  of  monkey  4  was  slightly  flattened  on  the  left  side 
in  its  superior-inferior  diameter.  This  was  probably  due  to  the 
usual  cause,  lack  of  sufficient  protection  from  the  bottom  of  the 
containing  vessel.  At  the  same  time  this  flattening  may  have 
been  accompanied  by  an  elongation  or  a  broadening  of  that  side. 
Since,  however,  the  two  sides  gave  approximately  (within  0.5 
mm.)  the  same  fronto-occipital  measurements  it  does  not  appear 
likely  that  there  has  been  much  variation  in  this  particular.  On 
the  other  hand,  the  variations  in  width  are  found  to  differ  for 
the  two  hemispheres  of  other  animals  and  it  is  impossible  to  say 
with  surety  that  the  superior-inferior  flattening  was  the  cause  of 
greater  width  of  the  left  hemisphere  of  this  animal.  When  the 
brain  of  monkey  5  was  removed  from  the  skull  both  occipital 
lobes  were  accidentally  cut  and  in  the  process  of  hardening  some 


Figure  i.  Representing  the  methods  of  making  the  linear  measurements 
which  are  given  in  the  text  and  in  Table  I:  a,  total  length;  b,  total  width; 
c,  frontal  length ;  d,  frontal  width ;  e,  length  of  central  fissure. 


94 


SHEPHERD  IVORY  FRANZ 


separation  of  these  parts  from  the  remainder  of  the  brain  oc- 
curred. When  the  brains  were  measured  these  parts  were  approx- 
imated to  the  remainder  of  the  brain  and  the  measures  made.  If 
there  is  an  inaccuracy  in  the  measurements  of  this  brain  because 
of  this  such  inaccuracy  relates  probably  solely  to  the  total  length. 
The  measurements  which  have  just  been  described  are  given  in 
Table  I  and  the  methods  of  taking  the  linear  measures  are  illus- 
trated in  Figure  i. 

Table  I.  Measurements  of  Monkey  Brains.  All  linear  measurements  are 
given  in  millimeters ;  those  of  mass  in  grams.  The  brains  of  monkeys  4  and  5 
were  somewhat  distorted  when  measured,  and  the  linear  measurements  may 
differ  slightly  from  those  given  here  (see  text,  page  93,  for  explanation). 


Frontal 

Lengths  ot 
Central  Fissure 

10 

Total 

Total 

Frontal  Widths 

Lengths 

■^ 

■55 

Monkeys 

Lengths 

Widths 

R 

L 

R 

L 

R 

L 

^ 

» 

70.0 

52.0 

21.5 

24.0 

34-0 

36.0 

32.0 

33-0 

69.0 

2 

67.5 

48.5 

23-5 

24.0 

32.5 

37-0 

330 

33-0 

65.0 

3 

74.0 

54-5 

24.5 

26.0 

41.0 

39-5 

36.0 

37-0 

81.5 

4 

67.5 

50.0 

21.0 

23.0 

350 

36.5 

33-0 

28.0 

59-5 

5 

66.0 

51.0 

24.0 

22.0 

36.5 

35-0 

29.0 

30-5 

60.5 

The  measurements  show  that  monkey  3  had  the  longest,  the 
widest,  and  the  heaviest  brain  and,  whether  measured  by  the 
product  of  frontal  width  x  frontal  length,  or  by  frontal  length 
X  length  of  the  central  fissure,  which  products  may  reasonably 
be  supposed  to  give  an  indication  of  the  extents  of  the  frontal 
areas,  also  the  largest  frontal  area.  This,  as  will  be  pointed  out  in 
a  subsequent  section  of  this  report,  is  of  special  interest  in  con- 
nection with  the  extent  of  the  stimulable  areas.  In  respect  to 
the  similar  measures  of  the  brain  of  monkey  i  it  will  be  noted 
that  the  right  hemisphere  of  this  animal  was  found  to  be  among 
the  smallest,  although  the  brain  weight  and  total  length  are 
greater  than  those  of  monkeys  2,  4  and  5.  At  the  same  time  it 
will  be  noted  that  the  brain  weight  of  monkey  2  is  the  median, 
that  the  total  width  is  the  least,  and  that  the  products  of  frontal 
width  X  frontal  length  and  frontal  length  x  length  of  central 
fissure  are  not  much  greater  than  those  of  the  brain  of  monkey  i. 


I.     EXTENTS  OF  CEREBRAL  MOTOR  AREAS  FOR  THE 
ARM  AND  LEG  SEGMENTS 

Monkey  4  died  shortly  after  the  stimulation  experiment  had 
been  begun  on  the  left  hemisphere.  Death  appeared  to  be  due 
to  an  excessive  hemorrhage  from  the  longitudinal  sinus  which 
had  not  been  suitably  ligated.  The  results  of  the  experiments 
on  this  animal  can,  therefore,  be  given  for  only  one  hemisphere 
and  in  this  case  the  comparison  of  the  two  hemispheres  is  im- 
possible. A  general  view  of  the  results  on  all  animals  is  given 
in  Figure  2.  As  has  already  been  mentioned,  the  points  of  stimu- 
lation have  'been  dealt  with  as  if  they  were  areas  corresponding 
with  the  spaces  surrounding  the  stimulation  points.  The  results 
of  the  experiments  on  each  hemisphere  are  shown  separately, 
the  digits  referring  to  the  monkeys,  the  upper  diagrams  showing 
the  results  of  the  exi>eriments  on  the  right  hemispheres,  and  the 
lower  diagrams  showing  those  on  the  left  hemispheres  of  these 
five  animals.  The  areas  for  the  leg  segment  movements  are 
represented  by  horizontal  lines  and  those  for  the  arm  seg- 
ment movements  by  vertical  lines.  The  heavy  horizontal  lines 
represent  the  respective  longitudinal  sulci,  other  heavy  lines 
represent  the  principal  fissures  (that  of  Rolando,  or  the  central 
fissure,  being  very  plain)  and  the  three  parallel  lines  indicate  the 
locations  of  the  principal  blood  vessels. 

It  will  be  first  noted  that  the  shapes  of  the  areas  differ  con- 
siderably. In  some  cases  the  areas  appear  to  run  practically  paral- 
lel to  the  central  fissures  (iR,  iL,  3R,  3L).^  In  other  cases  the 
form  of  the  areas  is  irregular,  broader  at  the  top,  or  near  the 
longitudinal  sulcus,  i.e.,  near  the  upper  portion  of  the  Rolandic 
fissure,  and  narrower  below.  It  is  also  to  be  noted  that  in  some 
cases,  and  in  all  hemispheres  in  certain  locations,  the  areas  are 
solid,  while  in  others  there  are  zones  in  which  no  leg  or  arm 
reactions  were  obtained.    In  some  of  these  cases  the  points  were 

'  These  figures  and  subsequent  ones  mean  monkey  i  right  hemisphere, 
monkey  i  left  hemisphere,  etc. 


96  SHEPHERD  IVORY  FRANZ 

apparently  "silent"  since  no  movement  of  the  arm,  trunk,  tail 
or  head  segments  followed  stimulation,  but  in  a  few  cases  on 
the  other  hand  the  stimulation  of  these  areas  gave  movements  of 
the  head  or  of  a  segment  other  than  those  which  are  dealt  with 
here  {i.e.,  arm  and  leg).  These  anomalous  results  will  be  dis- 
cussed in  a  later  section  of  this  article  (see  p.  134  ff.). 

A  third  difference  which  is  obvious  is  that  the  overlapping  of 
arm  and  leg  areas  is  irregular.  In  the  brain  of  monkey  i  none 
of  this  overlapping  was  discovered,  very  little  was  found  in  the 
brains  of  monkeys  3  and  4  and  more  was  found  in  the  brain  of 
monkey  5,  and  a  considerable  degree  of  overlapping  was  dis- 
covered in  the  brain  of  monkey  2.  These  overlappings  will  also 
be  dealt  with  in  a  subsequent  section  (see  p.  128  ff.). 

A  further  difference,  which  may  however  be  only  casual,  is 
that  the  dividing  line  between  the  leg  and  arm  areas  is  at  times 
well  marked  by  fissures  or  by  blood  vessels  and  in  the  brains  of 
other  animals  these  anatomical  landmarks  do  not  appear  to  have 
physiological  differentiating  characters.  Those  hemispheres  in 
which  fissures  and  blood  vessels  mark  off  the  two  areas  under 
consideration  are  iR,  iL,  2L,  3L,  and  5L.  I  do  not  think  that 
the  greater  frequency  of  this  in  the  left  hemispheres,  or  in  fact 
any  of  the  differences  in  this  particular  can,  with  our  present 
knowledge,  be  considered  to  be  of  physiological  significance. 

A  closer  examination  of  the  figures  also  reveals  well  marked 
differences  in  the  totals  of  the  stimulable  areas.  It  is  obvious 
from  inspection  that  the  stimulable  areas  of  2L  is  greater  than 
that  of  all  other  hemispheres  which  have  been  examined.  It  is 
also  apparent  that  in  this  respect  there  are  great  variations, 
hemisphere  4R  shows  the  smallest  area  and  the  remaining  seven 
hemispheres  are  intermediate  between  4R  and  2L.  As  has  al- 
ready been  indicated  (p.  91)  there  was  an  experimental  error 
in  connection  with  hemisphere  3L  inasmuch  as  there  was  a  possi* 
ble  line  bordering  upon  the  longitudinal  sulcus  which  was  not 
subjected  to  stimulation.  In  this  one  case  had  the  stimuli  been 
given  to  points  in  this  area  it  is  possible  that  the  leg  area  would 
have  been  found  to  extend  correspondingly  in  the  wedge  shape 
upwards  to  the  longitudinal  sulcus. 


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I      I      I I 1 I L 


98 


SHEPHERD  IVORY  FRANZ 


More  careful  measurements  of  these  areas  reveal  the  differ- 
ences which  are  observable  on  inspection.  The  figures  represent- 
ing these  measurements  are  given  in  Table  II.  The  measure- 
ments were  made   from  the  magnified    (lo  diameters)    charts 

Table  II.  Measurements  of  Areas  of  Stimulation  of  Monkey  Brains. 
Figures  marked  with  an  asterisk  are  probably  too  low.  For  explanation  of 
this  see  the  text,  page  91  • 


Hemispheres 

Areas  in  square  millimeters 

Per  cent 
Leg 

Monkeys 

Leg 

Arm 

Totals 

Overlappings 

Net 

Ann 

I 

R 
L 

il 

82 
71 

"5 
157 

0 
0 

"5 
157 

40 
121 

2 

R 

6i 

106 

167 

15 

152 

58 

L 

124 

125 

249 

34 

«i5 

99 

3 

R 
L 

57* 

103 
80 

128 
137* 

4 
5 

124 
132* 

24 
71* 

4 

R 

51 

34 

85 

7 

78 

150 

5 

R 

L 

79 
78 

83 
77 

162 
155 

23 
II 

U9 

144 

96 

lOI 

which  have  been  described,  by  the  aid  of  a  transparent  die 
divided  to  show  actual  square  millimeters  (in  the  magnified 
form  square  centimeters,  of  course)  which  was  placed  over 
the  areas.  Each  full  square  covering  the  stimulable  zone 
was  counted  as  one  and  each  part  square  as  one-half,  the 
latter  on  the  supposition  that  the  areas  larger  than  one-half 
would  counterbalance  those  smaller  than  one-half.  The 
results  of  this  comparatively  rough  method  were  compared  in  one 
case  with  the  similar  finer  method  of  using  a  die  with  spaces 
representing  half-millimeter  squares,  and  since  the  variations 
did  not  greatly  exceed  one  per  cent  the  original  measurements 
were  considered  to  be  sufficiently  accurate.  The  method  of 
measurement  is  also  obviously  exact  enough  in  view  of  the 
methods  which  were  employed  for  the  limitation  of  the  areas 
involved,  and  especially  in  view  of  the  magnified  representations 
of  the  areas  which  were  measured.  It  should  be  remarked, 
however,  that  a  turning  of  the  die  through  an  angle  of  30  degrees 
varied  the  measures  by  as  much  as  6  per  cent  but  even  with  this 
variation  the  figures  appear  to  be  sufficiently  exact  as  they  stand. 


k 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS        99 

In  connection  with  the  table  mention  may  be  made  again  of  the 
fact  that  in  hemisphere  3L  an  area  lying  next  to  the  longitudinal 
sulcus  was  not  stimulated.  The  figures  in  columns  3,  5,  7  and  8 
referring  to  this  hemisphere  are,  possibly,  too  low. 

At  the  present  moment  attention  should  be  directed  solely  to 
column  7  of  this  table  in  which  are  given  the  net  totals  of  the 
areas  which  were  found  to  be  stimulable.  These  figures  show  that 
the  stimulable  area  of  4R  is  the  smallest,  that  of  2L  the  greatest. 
In  terms  of  percentage,  using  the  lowest  figure  as  100,  we  find 
that  the  other  hemispheres  take  the  following  order  and  show 
the  following  percents:  iR  (149);  3R  (159);  3L  (169);  5R 
(178)  ;  2R  (195)  ;  iL  (201)  ;  2L  (276).  It  will  thus  be  seen 
that  the  greatest  area  (2L)  is  almost  three  times  as  large  as 
that  of  4R,  and  that  the  other  seven  hemispheres  vary  from 
50  per  cent  to  100  per  cent  greater  than  the  smallest. 

These  data  show  that  not  only  are  there  marked  variations 
in  different  animals,  but  also  that  the  variations  of  the  two 
hemispheres  of  the  same  animal  are  sometimes  great  with  re- 
spect to  the  stimulable  (motor)  areas.  These  differences  of 
the  two  hemispheres  of  the  same  animal  are  worthy  of  some 
notice.  In  all  four  monkeys  of  which  both  hemispheres  were 
investigated  and  measured  it  will  be  noted  that  the  stimulable 
areas  on  the  left  surpass  those  on  the  right.  In  the  case  of 
monkey  5  this  left-sided  preponderance  is  not  great,  only  3.6 
per  cent  and  therefore  within  the  error  of  measurement,  and 
similarly  in  the  case  of  monkey  3,  only  6.5  per  cent,  close  to 
the  error  of  measurement.  In  the  latter  case,  however,  there 
should  be  recalled  the  suggestion  (see  p.  96)  of  the  possi- 
bility that  the  leg  area  should  be  considered  to  be  larger  than 
it  is  sketched.  With  respect  to  monkeys  i  and  2  the  pre- 
ponderance of  the  left  side  is  great,  36  and  41  per  cent  re- 
spectively. In  the  next  section  a  further  analysis  of  these  figures 
will  be  made  to  determine  the  relative  areas  for  the  arm  and 
leg  movements  separately. 

To  what  factors  these  differences  correspond  is  at  present 
unknown.  Certain  of  the  general  objections  to  considering  them 
typical    of    the    motor    cortex    have    already    been    discussed 


100  SHEPHERD  IVORY  FRANZ 

(p.  89  ff.)  and  the  general  relation  of  the  differences  to  our 
conception  of  cerebral  activities  will  be  considered  in  the  section 
devoted  to  the  theoretical  discussion  (p.  140  ff.).  At  this  point, 
however,  it  may  be  well  to  show  the  general  lack  of  correspond- 
ence or  correlation  with  the  measurements  of  the  brain  which 
have  been  recorded  in  Table  I  (p.  94).  Monkey  3,  with 
the  greatest  brain  weight,  greatest  length  of  hemisphere,  and 
greatest  width  of  the  cerebrum  did  not  have  the  most  extensive 
motor  area  as  determined  by  the  methods  which  were  used  in 
the  present  work,  while  monkey  2,  with  one  of  the  smallest 
brains  in  the  series  showed  the  most  extensive  excitable  areas. 
If  the  measures  which  have  been  used  {frontal  length  x  frontal 
width,  and  frontal  length  x  length  of  central  fissure)  are  at  all 
typical  of  the  amount  of  the  cortex  of  the  frontal  areas,  it  is 
plain  that  there  is  no  direct  relation  between  the  extent  of  the 
motor  or  stimulable  cortex  and  the  total  amount  of  the  cortex 
anterior  to  the  central  fissure.  Such  a  conclusion  becomes  more 
evident  if  we  deal  with  the  data  regarding  the  other  hemispheres. 
The  only  apparent  fact  which  indicates  a  possible  relation  be- 
tween brain  size  (or  amount  of  frontal  cortex)  and  the  extents 
of  the  motor  area  is  that  there  is  a  closer  correspondence  be- 
tween the  relative  sizes  of  the  motor  areas  and  the  total  areas 
of  the  frontal  lobes  in  the  two  hemispheres  of  the  same  animal. 
Thus,  it  might  be  concluded  that  the  preponderance  of  the  motor 
area  of  the  left  hemisphere  is  an  indication  of  and  bears  a 
possible  correlation  with  the  (in  general)  larger  hemisphere 
measurements  on  that  side.  Monkey  i  whose  brain  showed 
greater  width,  greater  frontal  length,  and  greater  length  of 
the  central  fissure  on  the  left  showed  also  a  considerable  su- 
periority in  the  extent  of  the  motor  area  on  that  side.  The 
brain  of  monkey  2,  in  which  a  similar  superiority  in  size  was 
apparent,  except  for  fissure  length,  also  showed  a  larger  area 
on  the  left  side.  The  brain  of  monkey  3,  in  which  there  was 
a  greater  width  and  a  greater  fissure  length  on  the  left  while 
the  left  frontal  length  was  smaller  than  that  on  the  right  showed 
little  difference  in  the  relative  sizes  of  the  two  motor  areas. 
In  a  similar  manner  the  brain  of  monkey  5  showed  variations 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      loi 

in  measurements,  some  of  the  right  hemisphere  being  greater 
than  those  of  the  left  and  others  of  the  left  being  greater  than 
the  corresponding  measures  of  the  right  hemisphere.  The 
cerebral  measures  which  may  be  concluded  to  be  approximately 
balancing  for  the  two  sides  correspond  therefore  with  the  almost 
equal  distribution  of  the  motor  areas.  A  disturbing  element  to 
such  a  conclusion  is  due  to  the  unfortunate  failure  to  complete 
the  series  of  experiments  on  the  left  hemisphere  of  monkey  3. 
While  there  is  an  equal  reason  for  believing  that  if  the  stimuli 
had  been  given  in  this  area  there  would  and  there  would  not 
have  been  any  great  change  in  the  sum  totals  of  the  areas, 
at  least  the  case  must  tentatively  be  thrown  out  of  consideration. 
Another  fact  which  is  opposed  to  the  conclusion  of  such  a 
definite  relation  is  found  in  the  lack  of  correspondence  between 
the  relations  of  the  hemisphere  measurements  and  the  relations 
of  the  extents  of  the  excitable  zones.  Those  measurements  which 
have  been  taken  to  represent  the  areas  of  the  frontal  lobes 
(frontal  length  x  length  of  the  central  fissure,  and  frontal  length 
X  frontal  width)  do  not  have  the  same  or  nearly  the  same  pro- 
portions that  the  total  motor  areas  of  the  two  hemispheres  of 
the  same  animal  bear.  Thus  our  relative  measures  for  the 
brains  R/L  are  as  follows:  frontal  length  x  frontal  width, 
1=0.85,  2^0.86;  3  =  1.01;  5  =  0.99.  To  compare  with 
these  figures  we  have  the  similarly  calculated  relations  of  the 
two  motor  areas  of  the  same  brains  as  follows:  1=0.73; 
2  =  0.71;  3  =  0.94;  5  =  0,97.  The  absolute  figures  do  not 
show  a  close  correspondence  but  it  must  be  admitted  that  the 
measures  are  grossly  inaccurate  as  representing  the  area  of  the 
anterior  parts  of  the  cortex  of  the  cerebrum.  If  we  consider  the 
relative  figures  there  appears  to  be  a  closer  correlation  inasmuch 
as  the  relatively  smaller  motor  areas  on  the  right  (monkeys  i 
and  2)  may  be  compared  (not  directly,  however)  with  the 
smaller  cortical  zones  on  that  side.  At  the  same  time  the  nearly 
equal  motor  areas  (monkeys  3  and  5)  are  to  be  compared  with 
the  nearly  equal  cortical  zones  (or  with  the  preponderating  right 
hemisphere  of  monkey  5  as  indicated  by  frontal  length  x  frontal 


102  SHEPHERD  IVORY  FRANZ 

width).     We  can  conclude  with  certainty  that  if  a  relation  in 
this   respect  exists   it  is  neither  simple  nor  direct. 

Summwy.  The  motor  areas  for  the  leg  and  arm  segments 
dififer  in  size  in  the  brains  of  different  animals,  and  in  the  two 
hemispheres  of  the  same  animal.  These  differences  are  not  ac- 
counted for  by  the  size  variations  of  the  hemisphere  of  the 
the  different  animals  although  there  is  some  indication  of  a 
possibility  of  correlation  of  the  sizes  of  the  frontal  lobes  and 
the  extents  of  the  motor  areas  of  the  two  hemispheres  of  the 
same  animal. 


II.     RELATIVE  DISTRIBUTIONS  OF  AREAS  FOR  LEG 
AND  ARM  MOVEMENTS 

Figure  2  and  Table  II  also  contain  data  regarding  the  absolute 
and  relative  extents  of  the  respective  areas  for  the  movements 
of  the  posterior  and  the  anterior  limbs.  Examination  of  the 
parts  of  the  figure  and  of  columns  3,  4,  7,  and  8  of  the  table 
reveal  extensive  differences.  These  differences  are  (i)  varying 
amounts  of  cerebral  areas  in  different  animals  for  the  leg  and 
for  the  arm  movements,  (2)  varying  amounts  of  cerebral  areas 
in  the  two  hemispheres  of  the  same  animal  for  the  leg  and  for 
the  arm  movements,  (3)  variations  in  the  overlapping  or  mixing 
of  the  leg  and  arm  areas,  which  matter  will  be  reserved  for 
discussion  in  a  subsequent  section,  and  (4)  variations  in  the 
spatial  proportions  of  these  two  areas  in  the  same  hemisphere. 

The  individual  variations  in  extents  of  these  areas  should  first 
be  noted.  The  smallest  leg  area  was  found  in  3R,  the  largest 
in  2L.  The  smallest  arm  area  was  found  in  4R,  the  largest  in 
2L.  The  largest  leg  and  arm  areas  were  found  in  the  hemisphere 
with  the  largest  total  area,  which  as  noted  above  was  by  no 
means  the  largest  brain.  The  smallest  leg  area  was  not  found 
in  the  hemisphere  with  the  smallest  total  stimulable  zone,  but 
the  smallest  arm  area  was  found  in  the  hemisphere  with  the 
smallest  net  total  stimulable  area.  The  intermediate  sized  total 
areas  more  closely  correspond  with  the  order  of  magnitude 
of  the  leg  areas  than  with  those  of  the  arm  areas.  Thus  we 
find  the  order  of  magnitude  of  the  net  totals  of  the  stimulable 
zones  (combined  arm  and  leg  areas)  are  4R,  iR,  3R,  3L,  5R,  5L, 
2R,  iL,  and  2L;  the  order  for  the  leg  areas  is  3R,  iR,  4R,  3L, 
2R,  5L,  5R,  iL,  and  2L;  and  the  order  for  the  arm  areas  is 
4R,  iL,  5L,  3L,  iR,  5R,  3R,  2R,  and  2L.  The  serial  orders 
indicate  a  rough  correlation  between  the  individual  arm  and  leg 
and  the  net  total  areas,  with  a  greater  correspondence  of  net 
total  with  leg  areas.  When,  however,  the  percentage  relations 
of  the  individual  areas  are  considered  it  is  to  be  noted  that  the 
only  close  correspondence  is  in  the  hemispheres  in  which  the 
leg  and  arm  areas  are  nearly  equal  in  size.     Thus  we  find  in 


104  SHEPHERD  IVORY  FRANZ 

general  a  fairly  close  correspondence  in  the  cases  of  2L,  5R 
and  5L,  but  in  these  cases  with  the  leg  and  the  arm  areas 
each  about  one-half  of  the  total,  a  direct  and  proportional  corre- 
spondence is  obviously  the  only  possible  relation  that  can  exist. 
When  we  examine  the  table  we  find  that  in  only  monkey 
5  are  the  totals  of  the  areas  for  the  leg  and  for  the  arm  closely 
similar  for  the  two  hemispheres.  The  almost  exact  correspond- 
ence of  areal  distribution  for  the  leg  movements  is  noteworthy 
and  the  dififerences  in  the  sizes  of  arm  areas  in  this  animal  are 
not  great,  perhaps  not  much  greater  than  the  errors  of  record- 
ing and  of  calculation.  The  only  other  close  correspondence  is  for 
the  arm  areas  of  monkey  i,  but  in  this  case  the  variation  is 
approximately  fifteen  per  cent.  In  the  other  five  cases  (hemi- 
spheres) the  differences  are  greater,  the  variations  ranging  from 
18  to  over  icx)  per  cent.     In  the  left  hemispheres  of  monkeys 

I,  2  and  3,  the  leg  areas  are  larger  than  those  of  the  right. 
In  the  left  hemisphere  of  monkey  2  the  arm  area  is  the  larger, 
while  the  arm  area  is  larger  in  the  right  hemisphere  of  monkey  3. 
It  will  be  noticed,  therefore,  that  the  left  motor  areas  for  the 
leg  are  in  general  considerably  larger  than  those  on  the  right, 
while  a  reverse  condition  holds  for  the  arms  areas  of  the  two 
hemispheres  with  the  exception  of  monkey  2  and  also  with  the 
exception  that  the  differences  are  not  as  great. 

If  other  data  were  not  at  hand  such  variations  might  reason- 
ably be  thought  to  bear  a  possible  relation  to  the  sizes  of  the 
hemispheres,  but  an  examination  of  the  figures  in  Table  I  and 
comparisons  with  those  of  Table  II  show  that  no  such  relation 
exists. 

Coupled  with  the  individual  and  the  hemisphere  variations  of 
these  areas  we  may  also  consider  the  relations  to  each  other 
of  the  leg  and  arm  areas  of  the  same  hemisphere.  In  this 
comparison  we  note  even  greater  deviations  than  have  already 
been  discussed.  The  quotients  of  leg  area  divided  by  arm  area 
for  the  individual  hemispheres  are  shown  in  column  8  of  Table 

II.  The  smallest  is  that  of  3R,  the  largest  is  that  of  4R.  In 
three  hemispheres  (2L,  5R,  and  5L)  the  quotients  show  the 
two  areas  to  be  about  equal,  in  four  hemispheres  the  quotients 
show  considerable  spatial  superiority  of  the  arm  area  (iR,  2R, 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      105 

3R,  and  3L),  and  in  two  hemispheres  a  corresponding  superiority 
of  the  leg  area  (iL  and  4R).  Although  the  importance  of  the 
observation  is  not  apparent  it  is  interesting  to  find  that  in  the 
four  cases  in  which  figures  for  both  hemispheres  are  available 
the  relative  superiority  of  the  arm  area  is  more  noticeable  on 
the  right.  It  will  be  noted  also  that  in  three  of  these  cases 
(monkeys  i,  2,  and  3)  this  relative  superiority  is  larg«  and, 
in  the  other  case,  although  small,  it  is  indicated  by  a  difference 
of  at  least  5  per  cent. 

An  explanation  of  these  differences  cannot  be  given  at  the 
present  time.  I  greatly  regret  that  extended  observations  of  the 
behavior  of  the  animals  were  not  made  previous  to  the  experi- 
ments, for,  merely  to  speculate,  the  suggestion  occurs  that  these 
cortical  variations  may  have  some  relation  to  the  normal  activities 
of  the  individual  animals.  A  few  observations  regarding  the  use 
of  the  right  and  left  hands  of  some  of  the  animals  were  made 
but  the  data  are  so  few  that  they  give  no  clue  to  a  possible  rela- 
tion between  the  extensive  or  limited  arm  areas  in  one  hemisphere 
and  the  use  of  the  right  or  left  hand  or  arm.  It  is  for  our 
present  purposes  unfortunate  that  even  these  inadequate  tests 
were  not  continued  a  sufficient  length  of  time  with  one  animal 
to  make  certain  any  preference  in  the  employment  of  the  hands. 
The  suggestion  of  a  possible  correlation  of  the  areal  differences 
and  the  differences  in  behavior  is  directly  in  line  with  previous 
conceptions  of  cerebral  function,  especially  those  regarding  the 
relations  of  the  associational  areas  to  occupations  and  habits 
of  thought.  An  extended  series  of  observations  of  habits,  gen- 
eral activity,  etc.,  of  many  animals  is  needed  along  with  corre- 
sponding observations  of  the  stimulable  areas  before  the  truth 
of  such  a  supposition  can  be  determined. 

Summary:  The  atfigs  for  the  arm  and  for  the  leg  differ  ,to 
a  considerable^  extent  in  differgnL-animals,  and  to  an  eqqal 
degree  in  ihe  two  hemispheres  of^jtlie-  Riimf^  njiimni  The  leg 
areas  are  sometimes^arger  than,  more  frequently  smaller  than, 
and  at  times  approximately  equal  to  the  corresponding  arm  areas. 
In  the  two  hemispheres  of  the  same  animal  the  quotients  of 
leg  area  divided  by  arm  area  are  not  even  approximately  equal, 
the  proportions  varying  by  as  much  as  one  to  three. 


Ill    DISTRIBUTIONS  OF  THE  AREAS  FOR  THE  INDI- 
VIDUAL SEGMENTS 

Up  to  this  point  we  have  dealt  with  the  areas  for  the  arm 
and  leg  as  if  these  were  the  main  anatomical  (and  physiological) 
elements  which  were  to  be  considered.  It  is  obvious,  however, 
that  the  individual  segments  of  these  larger  anatomical  units 
are  worthy  of  more  and  closer  study.  We  shall  also  find  that 
the  variations  which  have  already  been  shown  to  exist  are  not 
only  paralleled,  but  in  a  number  of  cases  they  are  exceeded  in 
amount,  by  the  variations  in  relative  sizes  of  the  areas  for  the 
smaller  segments.  At  the  present  time  the  analysis  and  com- 
parison of  the  types  of  the  movements  have  not  been  attempted, 
nor  will  the  separate  finger  or  toe  movements  be  dealt  with 
individually.  For  the  present  study  I  have  made  'eight  groups 
of  movements  as  follows :  thigh,  which  includes  all  mass  move- 
ments of  the  leg  on  the  trunk,  such  movements  being  of  the 
upper  part  of  the  leg;  leg,  those  movements  at  the  knee;  foot, 
those  movements  at  the  ankle ;  toes,  movements  of  these  elements 
taken  collectively  and  not  at  the  present  time  differentiating  the 
movements  of  individual  toes ;  shoulder,  those  movements  of  the 
upper  arm  in  relation  to  the  remainder  of  the  body;  forearm, 
movements  of  the  elbow;  hand,  movements  of  this  organ  at 
the  wrist;  and  fingers,  movements  of  these  parts,  also  collectively 
without  differentiating  the  movements  of  the  individual  fingers 
or  the  thumb.  At  the  same  time  I  have,  for  the  present  disre- 
garded the  characters  of  the  movements,  (i)  whether  they  be 
flexions,  or  extensions,  or  rotations,  or  (2)  dealing  with  the 
movements  as  they  appear  in  their  complexity  as  behavior 
phenomena,  whether  they  be  of  a  thrusting,  or  of  a  grasping, 
or  of  a  propulsive,  or  a  reaching,  or  of  any  other  complex  nature. 
In  this  section,  therefore,  I  deal  with  the  movements  of 
anatomical  segments  and  not  with  the  movement  characters. 

Thigh. — The  distributions  of  the  areas  the  stimulation  of 
which  resulted  in  movements  of  the  thigh  are  shown  in  the 
diagrams  of  Figure  3.     The  relative  areal  variations  are  here 


1 — I — I — I — I — 1 — I — I — r 


3 

s 


a 


.» 


s 
^ 
s 


(it 


io8 


SHEPHERD  IVORY  FRANZ 


observed  to  be  much  greater  than  those  for  the  combined  leg 
segments  as  shown  in  Figure  2,  or  than  those  for  the  arm 
segment  as  shown  in  the  same  figure.  In  two  hemispheres, 
iR  and  3R,  these  areas  do  not  touch  the  longitudinal  sulcus, 
while  in  all  other  cases  (omitting  3L  which  as  has  already  been 
mentioned  was  not  sufficiently  investigated  in  this  respect)  the 
thigh  areas  border  upon  this  great  fissure.  It  is  also  to  be 
noted  that  with  the  exception  of  the  two  hemispheres  of  monkey 
I,  and  it  may  be  said  that  the  left  hemisphere  of  this  animal 
is  a  rather  doubtful  case  in  this  particular,  all  of  the  thigh  areas 
border  upon  the  central  fissure.  In  some  of  the  cases  the  loca- 
tions are  suggestive  of  outcroppings  from  the  central  fissure, 
and  of  extensions  of  similarly  functioning  cortical  zones  lying 
within  that  fissure.  In  the  same  way  we  may  consider  the  areas 
bordering  upon  the  longitudinal  sulcus  although  this  appears 
a  less  probable  explanation,  except  in  the  case  of  monkey  5. 
In  all  other  animals  there  is  a  constriction  of  the  area  towards 
the  longitudinal  sulcus,  the  greater  extents  being  on  the  convexity 
away  from  that  zone. 

The  extensive  variations  of  the  area  are  shown  in  the  ac- 
companying Table  III  which  gives  numerical  expression  to  the 
diagrams.     Reference  to  this  Table  will  be  sufficient  without 

Table  III.  Measurements  of  the  extents  of  the  thigh  areas.  The  figure 
marked  with  an  asterisk  is  probably  too  low  (see  page  91)  and  the  corre- 
sponding percentage  R/L  too  high. 


Monkeys 

I 

2 

3 

4 

5 

Hemispheres 

R        L 

R        L 

R        L 

R 

R        L 

Areas  in  square 

4-5      30.0 

47.5     107.0 

17.5    *i6.o 

25.0 

53-0      46.0 

mm. 

Percentages 
R/L 

IS 

44 

109 

— 

115 

Percentage    re- 
lations of  av- 

22 

100 

22 

32 

65 

erages,    Mon- 
key 2  =  100. 

VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      109 

any  textural  discussion,  since  the  data  are  self-explanatory. 
The  attention  of  the  reader  is  particularly  directed  to  the  two 
final  lines  in  which  are  noted  (i)  the  proportions  of  the  areas 
in  the  two  hemispheres  of  the  same  animals,  and  also  (2)  the 
percentage  relations  of  the  average  extents  of  these  areas  in 
the  five  animals,  using  the  largest  average  as  unity. 

In  addition  to  the  variations  in  the  absolute  and  relative  sizes 
of  these  areas  the  distribution  of  the  stimulable  zones  is  worthy 
of  remark.  With  the  exception  of  iR,  in  which  there  appears 
only  a  small  superficial  area,  all  brains  show  a  wide-spread 
distribution.  In  no  case  (except  iR)  is  the  area  solid,  but  the 
points  are  frequently  separated  by  the  cerebral  zones  for  other 
movements  or  by  the  so-called  silent  or  non-stimulable  areas. 
In  some  cases  this  separation,  which  will  also  be  found  illus- 
trated in  some  of  the  later  diagrams,  is  noteworthy  since  the 
separated  areas  are  within  the  zones  governing  the  movements 
of  the  arm  segments  and  also  because  they  are  at  such  relatively 
great  distances  from  the  main  masses  of  the  cortex  which  may 
appropriately  be  called  the  primary  areas.  In  iL  and  in  2L 
these  separations  are  especially  great. 

Leg. — Similar  variations  in  the  extents  and  in  the  distribution 
of  the  areas  governing  the  movements  of  the  lower  part  of  the 
leg  are  to  be  noted  by  inspection  of  the  diagrams  of  Figure  4 
and  the  data  in  Table  IV.  As  compared  with  the  areas  for 
the  thigh  movements  some  hemispheres  show  a  greater  leg  area 
(hemispheres  iR,  2R,  3R,  3L  and  5R)  while  others  (iL,  2L 
and  4R)  show  a  lesser  leg  area.  The  general  distribution  of 
the  areas  does  not  differ  markedly  for  these  two  segments,  al- 
though the  forms  of  the  areas  are  not  nearly  the  same.  Both 
thigh  areas  and  leg  areas  are  located  at  the  upper  portion  of 
the  fissure  of  Rolando  with  perhaps  a  little  more  extensive  ad- 
vance towards  the  lower  portion  on  the  part  of  the  leg  area. 
Most  of  the  points  in  both  areas,  as  can  be  seen  by  placing 
the  two  figures  together,  are  duplicates,  indicating  that  the  move- 
ments are  combined  movements  of  thigh  and  leg.  In  a  few 
cases,  especially  in  hemispheres  iR  and  3L,  the  leg  movements 
were  not  combined  with  movements  at  the  thigh. 


no 


SHEPHERD  IVORY  FRANZ 


The  percentage  relations  of  the  two  hemispheres  of  the  same 
animal  and  those  of  the  average  areas  in  the  five  animals  are 
very  great.    It  will  be  noticed  that  the  relation  R/L  varies  from 

Table  IV.  Measurements  of  the  extents  of  leg  areas.  The  figure  marked 
with  an  asterisk  is  probaibly  too  low  (:s«e  page  91)  and  the  corresponding 
percentage  R/L  too  high. 


Monkeys 

I 

2 

3 

4 

S 

Hemispheres 

R        L 

R        L 

R        L 

R 

R        L 

Areas  in  square 
mm. 

25-5      16.5 

56.5     89.0 

20.5    *30.5 

16.0 

60.0      46.5 

Percentages 
R/L 

155 

63 

67 

t»4 

129 

Percentage    re- 
lations of  av- 
erages,   Mon- 
key 2  =  100. 

29 

100 

35 

22 

74 

63  to  155  per  cent.  The  percentage  relations  of  the  average 
extents  of  the  areas  with  the  extents  of  the  areas  in  monkey 
2  as  unity  are  also  greatly  different,  ranging  from  22  to  74. 
In  no  case  do  these  proportions  correspond  with  the  proportions 
for  the  thigh  areas,  the  nearest  approach  to  correspondence  being 
in  the  case  of  monkey  5.  It  can  be  concluded,  therefore,  that 
neither  the  absolute  nor  the  relative  extents  of  the  areas  for 
the  thigh  and  leg  movements  closely  correspond. 

Foot.' — Variations,  both  for  absolute  and  relative  amounts  of 
the  areas,  similar  to  those  which  have  already  been  described 
for  the  thigh  and  leg  are  also  noticed  for  the  foot  areas.  These 
are  shown  in  the  diagrams  of  Figure  5  and  in  Table  V.  These 
variations  exist  not  only  for  the  different  animals  but  also  for 
the  two  hemispheres  of  the  same  animal.  In  the  latter  cases, 
however,  the  correspondence  is  closer  than  in  the  former.  If 
we  take  the  net  totals  as  standards,  that  is,  if  we  take  the  com- 
bined stimulable  zones  for  the  arm  and  leg  segments  as  standards 
for  each  hemisphere,  we  find  that  the  percentages  of  the  areas 


I — I — i — I — I — I — I — I — I — I — r— r 


03       J        / 


'■>''■■ I — I — I — I — I-  « — I — I — • — I— J — I — I— t. 


I — I — i — I — I — r — I — I — I — I — I — r 


I — I — I — I — I — I — I — I — 1 — I — I — r 


c 

'<n 


H 


L_l I I L 


I U-i. 


I..    I U_JL 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      113 
Table  V.    Measurements  of  the  extents  of  foot  areas. 


Monkeys 

I 

2 

3 

4 

5 

Hemispheres 

R        L 

R        L 

R        L 

R 

R        L 

Areas  in  square 
mm. 

9.0      23.0 

34-5       52.5 

13.5      35-0 

24.0 

50.5      42.0 

Percentages 
R/L 

39 

66 

39 

— 

120 

Percentage    re- 
lations of  av- 

37 

100 

56 

55 

163 

erages,    Mon- 
key 2  =  100. 

for  the  foot  movements  for  the  two  hemispheres  of  one  animal 
vary  in  two  cases  (monkeys  i  and  3)  and  do  not  vary  greatly 
in  the  other  two  cases  (monkeys  2  and  5).  In  relation  to  the 
standards  which  have  just  been  mentioned  we  find  the  foot 
areas  with  the  following  per  cents:  iR^8;  iL=i5; 
2R  =  23;  2L  =  25;  3R=ii;  3^  =  2?',  4R  =  3i;  5^=^36; 
5L  =  29.  In  other  words  the  total  extents  of  the  areas  gov- 
erning the  movements  of  the  foot  vary  from  9  per  cent.  (iR) 
to  36  per  cent.  (5R)  of  the  total  areas  for  arm  and  leg.  These 
percentage  data  do  not  correspond  closely  with  the  actual  ex- 
tents of  the  areas,  which  vary  from  9  sq.  mm.  (iR)  to  52.5 
sq.  mm.  (2L).  Nor  do  the  relations  R/L  of  actual  measure- 
ments have  the  same  proportions  and  the  same  serial  order 
as  the  relations  R/L  of  the  percentages  of  the  totals.  This 
failure  of  correspondence  is  due,  of  course,  to  the  varying  degree 
of  overlapping  areas  in  the  different  hemispheres.  The  over- 
lapping of  areas  does  not  entirely  change  the  relative  positions 
of  the  different  hemispheres,  however,  for  hemisphere  iR  still 
remains  the  lowest,  followed  by  3R.  The  position  of  4R  is, 
however,  considerably  changed  in  that  by  this  comparison  it 
shows  a  relatively  large  area  for  foot  movements  whereas  in 
absolute  amounts  it  is  the  fourth  lowest. 

Comparisons  of  the  areal  amounts  for  the  foot  with  those  for 


114  SHEPHERD  IVORY  FRANZ 

the  thigh  and  the  leg  show  many  interesting  relations.  In 
the  brains  of  monkeys  2  and  5  the  foot  areas  are  less  than 
either  the  thigh  or  leg  areas,  although  in  both  hemispheres  of 
monkey  5  the  superiority  of  the  thigh  over  the  foot  is  small 
and,  perhaps,  within  the  error  of  calculation.  In  3R  a  similar 
relation  holds,  although  on  the  left  the  reverse  condition  is 
found.  In  monkey  4  and  in  monkey  i  the  relation  is  not  con- 
stant, the  thigh  area  being  larger  than  the  foot  area  in  iL  and 
less  in  iR  and  in  4R. 

The  figure  illustrating  the  distribution  of  the  foot  areas  in 
the  different  hemispheres  shows  other  interesting  variations.  In 
a  number  of  cases  we  find  that,  unlike  the  corresponding  areas 
for  the  thigh  and  for  the  leg,  there  has  been  a  sort  of  diffusion 
or  scattering  of  the  foot  areas.  The  diagrammatic  representa- 
tion of  the  points  of  stimulation  shows  less  of  a  coalesced 
mass  and  more  individual  patches.  Whether  or  not  this  has 
any  anatomical  or  physiological  significance  cannot  be  deter- 
mined. A  similar  condition  will  later  be  noted  for  some  of  the 
areas  for  the  arm  segments. 

Another  matter  which  may  be  called  to  the  attention  of  the 
reader  is  the  occurrence  of  points  or  areas  for  "pure"  move- 
ments of  the  foot.  A  careful  comparison  of  figures  3,  4,  and 
5  shows  that  there  are  certain  points  in  the  foot  area  which 
have  no  overlapping  of  thigh  and  leg  areas,  and  a  further  com- 
parison with  figure  6  shows  a  similar  state  of  affairs  as  related 
to  toe  movements.  Thus  we  find  in  iR  a  small  area,  at  the 
upper  portion  of  the  fissure  of  Rolando  which  borders  upon  the 
longitudinal  sulcus,  which  is  not  duplicated  in  any  of  the  other 
three  diagrams  for  the  leg  movements  in  this  hemisphere.  Also 
in  iL  there  is  a  similar  zone  at  the  angle  of  the  large  blood 
vessel,  and  a  second  zone  at  the  extreme  upper  portion  of  the 
area.  Similar  zones  are  found  in  four  other  hemispheres;  in 
4R  at  the  extreme  right  upper  f>ortion,  in  5R  a  small  area  in 
the  lower  part  of  the  solid,  in  5L  another  zone  bordering  upon 
and  equidistant  from  the  indicated  extremities  of  the  blood 
vessel  and  towards  the  fissure  of  Rolando,  and  in  3L  a  zone 
of  this  character  at  the  left  end  of  the  solid  area.     It  will  thus 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      115 

be  seen  that  scattered  throughout  the  solid  area  for  the  leg 
there  is  found  an  occasional  zone  for  movements  of  one  portion 
of  the  anatomical  segment  uncomplicated  with  movements  of 
other  segments. 

Toes. — The  relative  positions  of  the  toe  areas  is  noteworthy. 
A  comparison  of  the  diagrams  in  Figure  3,  4,  5,  and  6  shows 
the  toe  areas  in  iR  to  be  higher^  than  the  thigh  area  and  in 
general  higher  than  the  foot  area  but  closely  approximating 
the  leg  area.  In  iL  the  area  is  massive  and  lies  nearer  the 
longitudinal  sulcus,  the  thigh  area,  with  the  exception  of  a  few 
points,  lying  lower  in  the  field.  For  2R  and  for  2L  similar 
statements  cannot  be  made,  for  in  general  the  toe  areas  of 
these  animals  lie  lower  down  than  the  areas  for  thigh  and  foot, 
although  they  approach  in  location  the  area  for  the  leg  move- 
ments. It  should,  however,  be  noted  that  in  these  hemispheres 
points  lying  much  lower  down  than  that  corresponding  to  the  toe 
area  were  found  for  the  thigh  and  leg  movements.  In  3R  the 
total  extensity  of  the  toe  area  is  much  less  than  that  for  any  of 
the  other  leg  elements  but  the  area  is  apparently  just  as  widely 
spread  over  the  cerebral  convexity.  In  3L  the  area  is  greater 
than  those  for  the  other  segments  and  to  a  slight  degree  it  is 
more  widely  spread.  In  4R  the  area  is  much  greater  and  extends 
higher  and  farther  backwards  than  the  other  areas.  In  5R 
the  area  is  the  least  extensive  of  the  four  leg  segments  and  it 
is,  unlike  that  for  the  foot  and  that  for  the  thigh,  compact.  5L 
is  also  an  area  without  divisions  and  is  more  compact  but  only 
slightly  smaller  than  the  other  three  areas  for  the  leg. 

It  is  to  be  noted,  therefore,  that  differences  exist  not  only 
with  respect  to  the  absolute  and  the  relative  sizes  of  this  area 
in  the  different  hemispheres  but  also  with  respect  to  the  diffusion 
or  compactness  of  the  area. 

At  the  same  time  mention  may  be  made  of  the  variations 
which  are  similar  to  those  which  have  already  been  described 
for  the  other  leg  segments.     We  find  the  absolute  amounts  of 

•"Higher"  and  "lower"  here  refer  to  the  diagrams,  and  these  terms  cor- 
respond to  the  anatomical,  but  more  cumbersome,  "nearer  the  longitudinal 
sulcus"  and  "farther  from  the  longitudinal  sulcus"  respectively. 


ii6 


SHEPHERD  IVORY  FRANZ 


the  areas  differing  in  the  different  animals,  and  at  the  same 
time  differing  in  the  two  hemispheres  of  the  same  animal.  More- 
over we  find  the  relative  amounts  of  the  areas  widely  different 
for  the  different  animals  and  for  the  two  hemispheres  of  the 
same  animal.  In  this  respect  there  is  an  agreement  with  the 
other  areas  which  have  previously  been  described.  In  iL,  3L, 
and  4R  the  toe  areas  exeed  those  for  the  thigh,  for  the  leg, 
and  for  the  foot;  in  2R,  2L,  5R,  and  5L  the  toe  areas  are 
exceeded  by  those  for  the  other  hind  limb  segments,  although 
the  excess  in  the  case  of  5L  is  slight  and  well  within  the  ob- 
servational error.  The  variations  in  totals  are  not  as  great  as 
those  which  have  been  noted  for  the  other  leg  segments,  nor  do 
the  percentages  in  relation  to  the  total  stimulable  areas  vary 
as  much.  The  hemisphere  to  hemisphere  variations,  with  the 
exception  of  those  of  the  brain  of  monkey  5,  are  considerable 
and  differ  in  some  cases  by  as  much  as  i  to  2.5.  The  results, 
diagrammatic  and  numerically,  are  given  in  Figure  6  and  in 
Table  VI. 

Shoulder. — The  totals  of  the  shoulder  areas  range  from  11.5 
sq.  mm.  (4R)  to  80.5  sq.  mm.  (2R),  with  percentages  in  rela- 
tion to  the  net  totals  (leg  and  arm  segments  together)  ranging 
from  15  (4R)  to  54  (3R).     The  differences  in  amount  of  the 

Table  VI.    Measurements  of  the  extents  of  toe  areas. 


Monkeys 

I 

2 

3 

4 

5 

Hemispheres 

R        L 

R        L 

R        L 

R 

R        L 

Areas  in  square 
nun. 

24.0      51.0 

20.5      52.5 

16.5      45-0 

33.5 

37-0      41-0 

Percentages 
R/L 

47 

39 

2,7 

— 

90 

Percentage    re- 
lations of  av- 

103 

100 

84 

92 

168 

erages,    Mon- 
key 2  =:  100. 

I — I — I — r— 1 — I    i    I — i—i — I — r 


.( — I — I — I — I — I — I — I — I — I — I — r 


J3 

H 


tlH 


l__l '      '      ' I t I l—i I — L 


I I I L 


I       I       I       I       I L 


\ — I — I — I — I — I — I — I — I — I — I — r 


I — I — I — I — I — I — I — I — I — I — I — r 


J L. 


'       ' I I I L. 


L_l l—J I I '       '       « U-X. 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      119 
Table  VII.    Measurements  of  the  extents  of  shoulder  areas. 


Monkeys 

I 

2 

3 

4 

5 

Hemispheres 

R        L 

R        L 

R        L 

R 

R        L 

Areas  in  square 

37.0      25.0 

80.5      79-5 

67.5      32.0 

"•5 

26.0      48.0 

mm. 

Percentages 
R/L 

148 

lOI 

211 

54 

Percentage    re- 
lations of  av- 

39 

100 

62 

14 

46 

erages,    Mon- 
key 2  =  100. 

areas  in  the  five  animals  are  greater  than  in  any  previous  area 
and  also  greater  than  any  of  the  areas  for  the  other  arm  seg- 
ments. The  amounts  and  the  illustrations  of  the  distributions 
of  these  areas  are  shown  in  Table  VII  and  in  Figure  7.  In 
relation  to  the  four  leg  segments  which  have  already  been  con- 
sidered there  are  four  hemispheres  in  which  the  shoulder  area 
exceeds  each  of  the  leg  segment  areas  (iR,  2R,  3R,  and  5L), 
there  are  two  hemispheres  in  which  the  shoulder  area  is  less 
than  each  of  the  leg  segment  areas  (4R  and  5R)  and  three 
hemispheres  in  which  two  of  the  leg  segment  areas  exceed  and 
the  other  two  are  less  than  the  shoulder  areas. 

The  variations  from  hemisphere  to  hemisphere  parallel  those 
which  have  already  been  discussed  for  other  segments,  the  great- 
est difference  being  found  in  monkeys  3  and  5,  where  the  dif- 
ferences are  approximately  100  per  cent. 

In  addition  to  the  differences  which  have  been  mentioned,  the 
wide-spread  distribution  of  the  shoulder  areas,  especially  in 
hemispheres  2L,  3R  and  5L,  is  noteworthy.  At  the  same  time 
the  discreteness  of  the  zones  is  a  prominent  feature  in  the 
illustrations.  There  is  also  to  be  noted  the  relation  of  the  areas 
to  the  central  fissure.  In  regard  to  this  it  will  be  observed 
that  the  areas  have  the  same  general  features  as  do  those  for  the 
thigh  movements  in  that  some  of  them  appear  to  be  outcropping 


lao 


SHEPHERD  IVORY  FRANZ 


or  projections  from  the  concealed  fissural  areas,  whereas  others 
are  less  apparently  related  to  those  hidden  areas.  At  the  same 
time  in  some  hemispheres  there  is  an  apparent  sharp  definition 
of  the  areas  by  the  principal  blood  vessels  and  by  fissures  other 
than  that  of  Rolando.  While  from  the  facts  now  at  hand  it 
cannot  be  said  that  these  divisions  by  fissures  and  by  the  principal 
blood  vessels  have  any  special  physiological  significance  the 
finding  of  this  in  relation  to  several  areas  gives  an  indication 
that  these  landmarks  may  have  some  physiological  as  well  as 
anatomical  meaning.  An  examination  of  all  the  diagrams  is 
suggestive  of  this  conclusion,  but  the  matter  needs  a  more  ex- 
tensive and  a  more  careful  study  with  a  definite  question  in  view. 

Forearm. — The  apparent  outcropping  of  the  zones  for  the 
forearm  from  similar  areas  located  within  the  infoldings  of  the 
fissure  of  Rolando  is  more  noticeable  than  in  any  other  previously 
considered  segment.  In  every  hemisphere  there  is  a  considerable 
extent  of  forearm  area  bordering  upon  the  central  fissure  and 
moreover  the  areas  appear  more  solid  than  those  for  the  shoulder 
movements.  This  does  not  mean,  however,  that  the  phenomenon 
of  diffusion  is  lacking  for  in  fact  an  examination  of  the  diagrams 
of  Figure  8  reveals  a  marked  degree  of  separation  of  the  areas 
in  2R,  2L,  3R,  and  5R. 

Table  VIII  gives  the  measurements  of  these  forearm  areas 

Table  VIII.    Measurements  of  extents  of  forearm  areas. 


Monkeys 

I 

2 

3 

4 

5 

Hemispheres 

R        L 

R        L 

R        L 

R 

R        L 

Areas  in  square 
mm. 

55-0      56.0 

89.5      92.5 

80.5      63.5 

24.0 

540      52.5 

Percentages 
R/L 

98 

97 

127 

— 

103 

Percentage    re- 
lations of  av- 

61 

100 

79 

26 

59 

erages,    Mon- 
kev  2  =  100. 

I — I — I — \ — I — I — I — I — I — I — r 


■     '     '     ■ I I — I — I — I — I — I — I 


122 


SHEPHERD  IVORY  FRANZ 


in  the  nine  hemispheres.  Here  are  shown  almost  as  great  dif- 
ferences as  have  been  shown  to  exist  for  the  other  areas  already 
dealt  with,  for  in  one  case  (monkey  4)  we  find  the  area  only 
about  one-quarter  the  size  of  that  in  monkey  2.  In  two  animals 
(monkeys  i  and  5)  the  areas  are  not  only  nearly  equal  but  the 
two  hemispheres  are  also  approximately  of  the  same  size.  This 
is  the  closest  correspondence  which  is  to  be  found  in  the  whole 
series  but  I  hesitate  to  conclude  that  it  has  any  great  significance. 

In  three  animals  the  proportions  R/L  are  nearly  equal  (monk- 
eys I,  2  and  5)  which  again  is  a  condition  not  found  for  any 
other  area,  but  which  I  also  doubt  has  any  well  marked  signifi- 
cance. The  reason  for  this  is  to  be  sought  in  the  varying  rela- 
tions of  the  extents  of  these  areas  to  the  net  total  (leg  plus 
arm  segments)  areas.  When  this  comparison  is  made  it  is  to  be 
observed  that  no  close  correspondence  exists  except  for  the  two 
hemispheres  of  monkey  5.  By  this  comparison  the  two  forearm 
areas  of  monkey  i  differ  by  25  per  cent.,  those  of  monkey 
2  by  an  almost  equal  amount,  and  the  differences  in  the  relations 
of  the  hemispheres  of  monkey  3  are  also  approximately  equal. 

Hand. — The  data  regarding  the  extensions  of  the  areas  con- 
trolling movements  of  the  hand  are  given  in  Table  IX  and  in 
Figure  9.  Unlike  many  of  the  areas  which  have  previously 
been  considered  these  areas  are  not  massed  but  are  widespread 

Table  IX.    Measurements  of  extents  of  hand  areas. 


Monkeys 

I 

2 

3 

4 

5 

Hemispheres 

R        L 

R        L 

R        L 

R 

R        L 

Areas  in  square 

390      39.5 

42.0      58.5 

37.0      18.5 

II.O 

32.0      16.5 

mm. 

Percentages 
R/L 

99 

72 

200 

— 

193 

Percentage    re- 
lations of  av- 

78 

100 

55 

22 

48 

erages,    Mon- 
key 2  =  100. 

r~T — 1 — I — 1 — I — I — I — I — I — I — r 


( — I — I — I — I — I — I — I — I — I — I — r 


'       '       '       I       '       '       I I 1 I I 1_  I 1 1 1 1 I I I I I I L^' 


124  SHEPHERD  IVORY  FRANZ 

and  divided  relatively  more  than  any  of  the  leg  segment  areas 
and  the  arm  segment  areas  with  the  exception  of  those  for 
foot  movements.  The  average  extent  of  this  area  for  all  hemi- 
spheres (32.7  sq.  mm.)  is  less  than  that  of  the  other  segment 
areas  with  the  exception  of  the  foot  areas  (average  31.7  sq.  mm.) 
and  the  variations  are  considerable.  Although  the  average  ex- 
tent of  this  area  is  among  the  smallest  it  has  wide  variations, 
for  in  monkey  i  it  is  exceeded  in  each  hemisphere  by  but  two 
of  the  other  areas,  in  monkey  2  it  is  exceeded  in  each  hemisphere 
by  four  other  areas,  in  monkey  3  it  is  exceeded  on  the  right 
by  three  areas  but  on  the  left  by  six  areas,  in  the  one  hemisphere 
of  monkey  4  it  is  exceeded  in  extent  by  seven  areas,  and  in 
monkey  5  on  the  right  by  seven  areas  and  on  the  left  by  all 
other  areas- 

The  variations  in  absolute  size  in  different  hemispheres  are 
great,  from  11  (4R)  to  58.5  sq.  mm.  (2L),  a  ratio  of  1:5.3. 
Its  relation  to  the  net  total  is  less  variable,  from  11  (5L)  to 
34  (iR),  although  the  ratio  is  slightly  greater  than  1:3.  In 
only  one  animal  (monkey  i)  are  the  areas  for  the  two  hemi- 
spheres nearly  equal  in  size,  although  in  relation  to  the  net 
totals  the  equality  is  greater  in  a  second  animal  (monkey  2). 

The  percentage  relations  of  R/L  show  only  one  instance  which 
has  previously  been  considered  (shoulder  area  of  monkey  3) 
in  which  the  difference  is  as  great  as  is  found  in  monkeys  3  and 
5  for  the  hand  areas.  These  figures  should,  however,  be  con- 
sidered to  be  no  more  than  suggestive  for  in  many  previous 
cases  (for  example,  thigh  areas  of  monkeys  i  and  2,  foot  areas 
of  monkey  i  and  3,  toe  areas  of  monkeys  i,  2  and  3,  etc)  if 
the  reverse  percentages  L/R  had  been  used  as  a  basis  of  com- 
parison the  differences  would  have  been  much  greater  in  these 
other  hemispheres. 

The  apparent  punctiform  character  of  the  area  under  con- 
sideration is  obvious  in  a  number  of  the  hemispheres.  Although 
exceeded  in  size  in  most  instances  by  the  other  areas  the  number 
of  divisions  greatly  exceeds  those  for  the  leg  and  toes,  slightly 
exceeds  those  for  the  thigh  and  fingers,  and  is  exceeded  only 
slightly  by  the  foot  and  forearm  areas  and  to  a  greater  degree 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      125 

by  the  shoulder  areas.  For  such  a  relatively  small  area  this 
wide-spread  distribution  is  noteworthy. 

In  form  the  areas  under  consideration  are  widespread,  the 
scattering  being  such  as  to  make  the  different  hemispheres  ap- 
pear to  be  without  resemblance,  and  this  statement  is  true  for 
the  two  hemispheres  of  the  same  animal  as  well  as  for  the 
hemispheres  of  different  animals.  The  relation  of  the  areas 
to  the  central  fissure  is  not  constant,  not  more  than  one-half 
of  the  areas  in  the  nine  hemispheres  having  close  association 
with  this  fissure.  With  the  exception  of  a  slight  relation  to 
a  subsidiary  fissure  in  2L  the  areas  do  not  appear  to  bear  a 
close  relation  to  the  other  fissures  and  principal  blood  vessels, 
and  to  employ  again  the  figure  of  speech  which  has  previously 
been  used  it  may  be  said  that  most  of  the  cortex  which  re- 
sponded with  movements  of  the  hand  appears  to  be  outcroppings 
from  the  depths  or  upward  projections  from  possible  underlying 
areas. 

A  comparison  of  the  total  areas  in  Table  IX  with  those  in 
Tables  VII  and  VIII  shows  that  in  all  hemispheres  the  hand 
area  is  less  in  extent  than  that  for  the  forearm  and  in  monkeys 
2  and  3  less  than  that  for  the  shoulder,  but  in  monkey  i  it  is 
greater  than  that  of  the  shoulder  area  while  in  monkeys  4  and  5 
the  relations  are  irregular  or  undecided. 

If  the  data  which  have  been  given  were  to  be  interpreted  in 
a  manner  which  is  not  infrequent  we  might  conclude  from 
the  relative  measurements  that  in  general  the  hand  of  these 
monkeys  has  only  the  same  amount  of  cerebral  control  as  the 
foot,  but  that  in  specific  instances  the  hand  has  a  greater  amount 
of  cerebral  control  and  in  other  cases  the  foot  is  the  part  best 
represented  in  the  cortex.  Such  a  conclusion  appears  to  me 
obviously  premature,  for  even  though  it  may  prove  to  be  true, 
at  present  we  do  not  know  exactly  what  cortical  stimulability 
means  and  I  believe  we  should  not  conclude  from  a  comparison  of 
two  sets  of  measurements  that  we  are  dealing  with  information 
regarding  lesser  or  greater  cerebral  control.  The  movements  of 
the  hand  areas,  it  will  later  be  noted,  are  more  often  associated 
with  movements  of  the  other  arm  segments  than  are  those  of  the 


126 


SHEPHERD  IVORY  FRANZ 


foot  with  the  other  leg  segments,  and  the  matter  of  greater  or 
lesser  cerebral  control  appears  to  me  to  be  bound  up  with  the 
character  of  the  distribution  as  well  as  with  the  superficial  extents 
of  the  areas  from  which  such  movements  may  be  produced  by 
stimulation  methods.  It  seems  to  me,  therefore,  that  the  element 
of  complexity  is  an  important  factor,  and  that  the  question  of  the 
greater  or  less  control  should  be  considered  only  in  the  light  of  all 
the  data  for  all  the  segments. 
Fingers. — Figure  lo  and  Table  X  contain  the  results  relative 


Table  X. 

Measurements  of  extents 

of  finger  areas. 

Monkeys 

I 

2 

3 

A 

5 

Hemispheres 

R        L 

R        L 

R        L 

R 

'  R        L 

Areas  in  square 

55-5      15-0 

40.0      57-5 

41.0      46.5 

lO.O 

35-5      40.5 

nun. 

Percentages 
R/L 

370 

70 

89 

— 

88 

Percentage    re- 
lations of  av- 

72 

100 

90 

21 

76 

erages,    Mon- 
key 2  =  100. 

to  the  areas  for  finger  movements.  Although  some  of  these 
areas  are  smaller  than  the  corresponding  areas  for  the  hand  they 
average  about  fifteen  per  cent  more  than  the  latter.  In  only  a 
few  cases  are  the  differences  great  enough  to  warrant  note, 
the  variations  in  hemispheres  iL  and  3L  and  5L  being  the 
greatest. 

The  comparative  range  of  the  areas  for  all  hemispheres  is 
approximately  i :  6,  which  is  nearly  the  same  proportion  obtained 
for  most  of  the  areas  which  have  previously  been  dealt  with. 
The  diagrams  of  Figure  10  show  the  closer  relation  of  the  areas 
to  the  central  fissure  than  is  to  be  found  with  some  of  the  other 
areas,  since  comparatively  large  portions  of  this  area  border 
upon  this  fissure.  This,  in  other  cases,  has  been  considered  to  be 
an  indication  of  the  possibility  that  large  or  small  cortical  areas 


128 


SHEPHERD  IVORY  FRANZ 


for  such  movements  may  be  concealed  within  the  Rolandic  fis- 
sure. If  this  be  true  the  sizes  of  the  finger  areas  would  be  much 
greater  than  those  which  are  shown  in  the  diagram  and  in  the 
table. 

General. — For  purposes  of  comparison  I  think  we  are  justi- 
fied in  combining  the  totals  of  the  stimulable  areas  regardless  of 
overlapping,  especially  since  these  totals  in  relation  to  the  net 
totals  will  give  some  indications  of  the  extents  of  the  overlappings 
from  area  to  area,  and  consequently  they  also  give  indications  of 
the  complexities  of  the  movements  of  the  different  hemispheres. 
The  general  relations  are  shown  in  Table  XL     In  this  table 

Table  XL  The  overlapping  of  areas  for  the  leg  and  arm  segments.  The 
totals  of  all  areas  were  obtained  by  adding  the  totals  for  each  hemisphere, 
and  the  amounts  of  overlapping  by  subtracting  from  these  figures  the  "net 
totals"  given  in  Table  II. 


I 

Hemispheres 

R 

L 

Totals     of     all 

249.5 

256.0 

areas 

Net   totals 

115.0 

157.0 

Overlappings 

134-5 

99.0 

Per  cent,  over- 
lappings in  re- 
lation   to    net 
totals 

117 

63 

2 

3 

4 

5 

R         L 

R         L 

R 

R 

L 

41 1. 0  589.0 

294.0  287.0 

155-0 

348.0 

333-0 

152.0  215.0 

124.0   132.0 

1 

78.0 

139.0 

144.0 

259.0  374.0 

170.0  155.0 

77.0 

209.0 

189.0 

170        174 

137        117 

99 

150 

131 

are  shown  (a)  the  totals  of  the  areas  which  have  been  considered, 
that  is  the  sum  totals  of  the  thigh,  the  leg,  the  foot,  etc.,  areas 
for  all  nine  hemispheres,  {h)  the  net  totals,  that  is  the  amount 
of  superficial  space  covered  by  the  areas,  (c)  the  differences 
between  these  sets  of  figures,  which  give  the  total  amounts  of 
overlapping  of  the  individual  areas,  and  {d)  the  percentage 
relations  of  the  amounts  of  overlappings  to  the  net  totals  of  the 
hemispheres.  It  is  obvious  that  if  the  series  of  stimuli  on  one 
hemisphere  produced  a  combined  movement  of  all  the  segments 
which  we  have  been  considering  there  would  be  a  total  of  over- 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      129 

lapping  amounting  to  700  per  cent  of  the  net  total  for  that 
hemisphere,  because  each  of  the  segments  would  be  totally  repre- 
sented in  the  grand  total.  The  greater  percentage  of  overlapping 
is,  therefore,  an  indication  of  greater  complexity  of  movement. 
In  the  next  section  we  shall  deal  with  the  special  overlappings  of 
the  arm  segments  in  the  leg  area  and  of  the  leg  segments  in  the 
arm  areas  and  here  we  shall  confine  ourselves  to  the  consideration 
of  the  special  overlappings  of  the  arm  segments  among  themselves 
and  of  the  leg  segments  among  themselves.  This  includes  at  the 
same  time  the  borderline  overlappings,  since  these  border  areas 
cannot  be  considered  to  be  distinctively  either  arm  or  leg  areas. 

The  smallest  amounts  of  overlapping  was  found  in  4R  and  in 
iL,  the  greatest  in  2L  and  in  2R.  The  differences  in  this  respect 
range  from  yy  to  374  sq.  mm.,  or  approximately  1:5.  In  rela- 
tion to  the  net  totals,  probably  a  fairer  means  of  comparison  of 
the  individual  hemispheres  with  one  another,  the  range  is  from 
63  to  1 74  per  cent,  or  approximately  i :  3.  An  interesting  fact 
is  that  in  iR,  in  which  it  has  been  noted  (p.  96)  that  no  over- 
lapping of  leg  and  arm  areas  occurred,  the  total  amount  of  the 
overlapping  exceeded  that  of  4R,  in  which  leg-arm  overlapping 
was  found,  and  the  total  amount  of  the  overlapping  is  not  marked- 
ly less  in  iR  than  in  3L  in  which  the  amount  of  overlapping  of 
the  leg  and  arm  segment  areas  is  considerable.  At  the  same 
time  the  percentage  relations  give  equally  interesting  figures 
regarding  the  same  thing,  for  it  is  to  be  observed  that  the  per- 
centage of  overlapping  in  iR  is  greater  than  that  of  4R,  equal 
to  that  of  3L  and  is  not  greatly  exceeded  by  that  of  5L,  in  all 
of  which  hemispheres  the  amount  of  overlapping  of  the  leg-arm 
areas  is  not  especially  small.  This  indicates  that  in  hemisphere 
iR  there  has  been  a  more  general  complexity  of  movement  for 
the  two  segments  we  have  considered  than  for  the  other  hemis- 
pheres just  mentioned  since  a  certain  percentage  of  the  over- 
lappings in  the  other  hemispheres  is  due  to  combinations  of  arm 
and  leg  movements.  The  low  percentage  in  iL  may  be  considered 
a  typical  example  of  what  may  be  expected  when  the  two  seg- 
ments have  not  overlapped. 

The  complications  or  the  combinations  of  movements  are  also 


130 


SHEPHERD  IVORY  FRANZ 


shown  by  the  number  of  cases  in  which  the  areas  for  one  segment 
overlap  those  of  the  other  segments.  These  data  for  the  leg 
segments  are  shown  in  Table  XII  and  those  for  the  arm  segments 

Table  XII.  Overlappings  of  leg  segment  areas.  Digits  represent  the 
numbers  of  hemispheres  in  which  overlapping  occurred.  The  total  possi- 
bilities are  nine  in  each  case. 


Segments 

Toes 

Foot 

Leg 

Thigh 

Toes 

— 

8 

8 

7 

Foot 

8 

9 

9 

Leg 

8 

9 

9 

Thigh 

7 

9 

9 

— 

in  Table  XIII.    In  these  tables  there  are  shown  the  total  number 5 

Table  XIIL  Overlappings  of  arm  segment  areas.  Digits  represent  the 
numbers  of  hemispheres  in  which  overlapping  occurred.  The  total  possi- 
bilities are  nine  for  each  case. 


Segments 

Shoulder 

Forearm 

Hand 

Fingers 

Shoulder 

— 

9 

9 

8 

Forearm 

9 

— 

9 

9 

Hand 

9 

9 

9 

Fingers 

8 

9 

9 

— 

of  cases  in  which  overlappings  occurred,  not  the  individual  points 
in  the  areas,  and  consequently  not  the  totals  of  the  areas  or  the 
total  portions  of  the  cortex  representing  the  areal  distribution 
of  movements  of  the  segments.  If  one  area,  for  example  that  of 
the  shoulder,  should  have  an  overlapping  in  all  hemispheres  it 
is  clear  that  the  table  would  show  a  total  overlapping  in  nine 
hemispheres.  Similarly  for  the  other  segments.  When  the  num- 
ber is  less  than  nine,  it  means  that  in  one  or  more  hemispheres 
at  no  time  in  the  whole  series  of  experiments  upon  those  hemi- 
spheres did  combined  movements  of  the  two  segments  occur. 
The  tables  show  that  in  two  cases  (iR  and  iL)  there  was  no 
overlapping  of  the  thigh  and  the  toe  areas,  in  one  case  (iR)  there 
was  no  overlapping  of  the  foot  and  toe  areas,  and  in  one  case 
(iL)  there  was  no  overlapping  of  the  toe  and  leg  areas.  In 
view  of  the  fact  that  in  iR  no  overlapping  took  place  of  thigh 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      131 

and  toe,  and  foot  and  toe,  the  small  percentages  of  overlapping  is 
understandable,  and  this  is  the  more  noticeable  also  because  of 
the  failure  to  find  from  cortical  stimulation  in  this  animal  com- 
bined movements  of  the  arm  and  leg. 

The  almost  universal  overlapping  in  the  arm  segments  areas 
indicates  the  general  complexity  of  the  movements  which  were 
obtained  by  the  stimulation  of  the  cortex  in  this  area,  and  at  the 
same  time  it  shows  that  the  complexity  is  found  in  all  hemispheres 
with  the  exception  of  shoulder-finger  relations  of  hemispheres 
iL.  It  does  not  show,  however,  that  there  is  the  same  degree  of 
complexity  for  all  other  hemispheres,  for  to  settle  the  latter  matter 
there  must  be  a  comparison  of  the  individual  points  which  it  is 
not  possible  to  make  at  this  time.  It  may  be  said,  however,  that 
there  are  considerable  variations  in  complexity  (hemisphere  and 
animal)  shown  by  the  examination  of  the  protocols  of  the  indi- 
vidual tests,  and  these  are  partly  indicated  by  the  differences  in 
the  totals  of  overlappings  which  are  shown  in  Table  XI.  It  may 
be  repeated  that  the  results  in  Tables  XII  and  XIII  do  not  mean 
that  there  has  been  a  total  overlapping  of  all  segments  in  all 
hemispheres  for  all  the  points  which  were  stimulated.  In  fact 
from  Table  XI  we  can  conclude  that  at  the  most  (2L)  there 
has  been  less  than  two-thirds  of  the  total  possible  amount  of 
overlapping  and  in  most  cases  the  amount  of  the  overlapping  is 
not  more  than  two-sevenths  of  the  possible  total,  and  usually 
much  less  than  this  amount.  If  there  were  no  overlapj pings  of 
arm  and  leg  segments  and  there  was  a  complete  overlapping  of 
the  areas  for  the  individual  parts  of  the  segments,  which  would 
mean  that  when  any  motor  point  was  stimulated  the  resulting 
reaction  would  be  a  movement  of  thigh  +  leg  +  foot  +  toes,  or 
a  movement  of  shoulder  +  forearm  -\-  hand  -{-  fingers,  we 
should  have  a  total  overlapping  of  300  per  cent.  A  considerable 
amount  of  overlapping  occurs  in  relation  to  the  leg  and  arm 
segment  areas  so  that  the  greatest  recorded  amounts  (2L,  374 
per  cent)  are  made  up  of  extra-segmental  overlappings  and  of 
inter-segmental  overlappings.  Table  II,  column  6  (p.  98) 
shows  the  amount  of  extra-segmental  overlappings,  and  the  fig- 
ures should  be  subtracted  from  those  in  Table  XI.   It  should  also 


132  SHEPHERD  IVORY  FRANZ 

be  remembered  that  the  figures  in  Table  II  do  not  represent  the 
totals  of  extra-segmental  overlappings  but  only  those  of  total-leg 
and  total-arm,  for  such  overlappings  may  be  of  two  or  more  parts 
of  each  of  the  two  segments  (arm  and  leg)  with  which  we  have 
been  dealing.  When,  however,  the  subtraction  which  is  sug- 
gested has  been  made  we  find  that  there  is  a  noticeable  reduc- 
tion in  some  of  the  figures  in  Table  XL  At  the  same  time  it 
should  not  be  thought  that  in  dealing  with  the  relation  of  the 
cerebral  cortex  to  complexities  of  movement  such  subtractions 
should  be  made,  for  in  general  it  is  true  that  the  greater  the 
overlappings  the  greater  is  the  degree  of  movement  complexity. 

Thus,  stimulation  of  the  cortex  at  the  border  of  the  two 
large  areas  produced  complex  movements  of  the  two  totalized 
segments.  We  found  for  example  movements  of  all  the  arm 
segments  towards  the  leg  and  at  the  same  time  complementary 
movements  of  the  leg  towards  the  arm.  Such  movements  are 
well  represented  by  those  of  the  intact  animal  when  he  wishes 
to  scratch  his  leg,  but  makes  only  part  of  the  movement,  that 
pertaining  to  the  approach  of  the  hand  and  fingers  to  the  leg 
and  a  similar  approach  of  the  leg  towards  the  hand  so  that  the 
latter  has  a  better  chance  for  scratching.  Also,  such  a  movement 
as  the  transfer  of  food  from  the  hand  to  the  foot  is  of  this  com- 
plex type,  and  similarly  with  movements  which  simulate  or 
resemble  those  of  the  simultaneous  use  of  the  arm  and  leg 
segments  in  the  act  of  taking  hold  of  the  bars  of  the  cage.  Such 
movements  are  on  the  other  hand  not  always  simultaneus,  not 
infrequently  it  was  found  that  after  the  arm  had  made  a  definite 
njovement  the  leg  would  make  a  movement  succeeding  that  of 
the  arm. 

Summary.' — The  data  show  that  in  different  animals  and  in 
different  hemispheres  a  variety  of  distribution  of  the  areas  con- 
cerned with  the  movements  of  the  individual  segments  of  the  leg 
and  arm.  In  addition  to  this  variation  in  distribution,  varia- 
tions in  the  total  amounts  of  the  different  areas  were  found, 
which  when  averaged  for  all  hemispheres  show  the  forearm  area 
of  greatest  size,  with  the  foot  area  of  the  smallest  average  size, 
and  between  these  extremes  and  in  serial  order  the  areas  for 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      133 

the  shoulder,  the  leg,  the  thigh,  the  fingers,  the  toes,  and  the 
hand.  It  will  be  noticed  that  in  all  cases  the  average  of  a 
segment  of  the  arm  exceeded  in  areal  size  that  of  the 
corresponding  segment  of  the  hind  limb,  i.e.,  the  area  for  the 
shoulder  movements  was  on  the  average  greater  than  that  for 
thigh  movements,  that  for  'forearm  movements  greater  than 
that  for  leg  movements,  etc.  In  the  individual  hemispheres 
such  relations  do  not  exist,  in  some  cases  the  leg  areas 
being  correspondingly  larger  than  the  arm  areas.  At  the  same 
time  the  serial  order  for  the  segments  is  not  the  same  for  all 
animals,  in  one  case  the  thigh  area  being  the  largest,  in  another 
hemisphere  the  forearm  area  being  the  largest,  etc.  The  shapes 
of  the  corresponding  areas  in  the  nine  hemispheres  did  not  ap- 
proximately correspond  nor  was  there  a  correspondence  of  the 
spatial  relations  of  the  areas  to  such  well  marked  anatomical 
landmarks  as  the  central  fissure,  the  longitudinal  sulcus,  etc.  In  a 
few  cases  the  anatomical  dividing  lines  appeared  to  have  a  cer- 
tain physiological  significance,  but  in  other  cases,  and  especially 
in  relation  to  certain  areas,  this  was  not  indicated.  In  all  hemis- 
pheres excepting  those  of  one  animal  there  was  found  a  greater 
or  less  overlapping  of  the  areas  for  the  leg  and  arm  segment 
movements,  which  was  shown  by  the  production  of  combined 
reactions  of  these  segments.  In  all  hemispheres  without  excep- 
tion there  were  found  overlappings  of  the  areas  for  the  in- 
dividual segments  of  the  leg  and  arm,  which  was  shown  by 
the  complex  movements  of  these  parts.  These  overlappings 
varied  in  all  hemispheres,  by  which  is  meant  that  the  stimulation 
of  the  cortex  of  some  hemispheres  resulted  in  more  of  the 
complex  movements  than  did  that  of  others. 


IV.     ANOMALOUS  DISTRIBUTIONS  OF  THE  STIMU- 

LABLE  AREAS 

Arm  movements  within  the  leg  areas. — In  the  broadest  sense 
we  may  consider  that  the  leg  segment  area  is  that  area  within 
which  stimulation  produces  leg  movements,  and  the  arm  area  that 
area  within  which  stimulation  produces  arm  movements.  Taking 
this  definition  of  the  areas  we  should  need  to  consider  that  the  leg 
areas  or  the  arm  areas  are  not  massed  but  are  spread  over  the 
precentral  cortex  as  widely  as  the  zone  in  which  a  stimulation 
at  any  point  produces  such  movements.  For  a  better  limitation  of 
the  areas  we  must  not  deal  with  the  widely  spreading  areas  in 
this  manner,  but  limit  the  designation  of  the  individual  areas  to 
those  solid-like  combinations  of  zones  in  which  the  special  char- 
acter of  movements  are  uniformly  or  nearly  uniformly  obtained. 
By  thus  dealing  with  our  results  we  can  say  that  in  general  there 
is  a  leg  area  separate  and  distinct  from,  but  contiguous  to,  the 
arm  area,  and  that  there  is  a  similar  arm  area,  but  that  between 
the  two  areas  there  is  an  intermediate  zone  which  is  allied  to 
both,  or  which  is  both,  and  which  can  be  considered  to  be  a  com- 
bined arm  and  leg  area. 

By  the  limitation  or  the  definition  of  the  areas  in  this  manner 
we  find  that  there  remain  certain  areas  or  points  within  each  of 
the  principal  areas  which  are  associated  with  the  production  of 
movement  of  another  segment  separate  from  the  segment  with 
which  the  area  has  definite  connections.  Thus  we  find  that  arm 
movements  are  sometimes  produced  by  the  stimulation  of  areas 
which  are  enclosed  on  all  sides  by  zones  which  are  distinctively 
leg  movement  areas  since  only  leg  movements  are  produced  by  the 
stimulation  of  the  cortex  in  these  regions  and  at  the  same  time 
there  are  arm  areas  within  which  stimulation  sometimes  pro- 
duces leg  movements.  These  areas  are  different  from  the  border- 
ing areas  in  that  the  results  are  unlike  those  for  the  surrounding 
zones,  and  are  therefore  to  be  considered  anomalous,  while  the 
bordering  areas  are  "normally"  the  combinations  wbich  are 
expected  in  view  of  the  continuity  of  the  whole  stimulable  zone. 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      135 

An  examination  of  Figure  2  shows  that  there  are  no  bordering 
combination  areas  in  the  hemispheres  of  monkey  i  but  that  such 
areas  are  found  in  all  the  other  hemispheres.  It  will  also  be 
observed  that  there  are  no  anomalously  distributed  areas  in  the 
hemispheres  of  monkey  i  and  none  in  2R,  but  that  the  other 
six  hemispheres  show  anomalous  areas.  In  2L  we  find  an  area 
of  this  character  with  a  considerable  extensity  having  its  upper 
border  contiguous  to  the  longitudinal  sulcus  and  extending  down- 
wards towards  the  fissure  of  Sylvius  along  the  principal  blood 
vessels  which  is  illustrated  in  the  diagram.  We  also  find  in  this 
hemisphere  a  small  area  which  is  related  to  arm  movement  con- 
trol, for  movements  of  the  shoulder  were  produced  by  the  stimu- 
lation of  this  area  although  the  stimulation  of  the  same  points 
gave  leg  movements  and  the  stimulation  of  the  surrounding  areas 
also  gave  purely  leg  movements.  Similar  zones  were  found  in 
the  hemispheres  of  monkey  3 ;  on  the  right  at  the  extreme  frontal 
border  of  the  area  points  were  found  the  stimulations  of  which 
were  followed  by  movements  of  the  forearm  as  well  as  of  the 
leg  segments,  and  on  the  left  side  a  similar  zone  in  the  center 
of  the  leg  area  the  stimulations  of  which  produced  simultaneous 
movements  of  the  segments  of  the  leg  and  of  the  shoulder.  In 
monkey  5  there  were  also  found  on  the  right  side  a  combined 
area  bordering  upon  the  longitudinal  sulcus  which  stimulations 
showed  was  associated  with  the  production  of  forearm  move- 
ments as  well  as  with  leg  movements,  and  a  second  area  some- 
what lower  in  the  field  which  gave  similar  combinations  of  fore- 
arm and  leg  movements,  in  the  left  hemisphere  of  this  animal 
the  combined  area  bordering  upon  the  longitudinal  sulcus  gave 
movements  of  the  shoulder  in  addition  to  the  leg  segment  move- 
ments which  were  noted  in  the  protocol  of  the  experiment  as 
follows:  "extension  of  toes,  followed  by  extension  of  the  leg 
and  thigh,  and  a  movement  of  the  tail  to  the  right,  with  a  mass 
movements  of  the  arm  such  as  is  made  when  lifting  the  shoulder." 

The  general  results  regarding  the  amounts  of  overlappings  of 
the  arm  and  leg  segment  areas  are  shown  in  Table  XIV.  This 
table  shows  only  the  general  view  of  the  relations  as  indicated  by 
the  overlappings  of  the  different  areas,  without  considering  the 


136 


SHEPHERD  IVORY  FRANZ 


Table  XIV.  Overlapping  of  leg  and  arm  segment  areas.  Digits  represent 
the  numbers  of  hemispheres  in  which  overlapping  occurred.  The  total  possi- 
bilities are  nine  in  each  case. 


Segments 

Toes 

Foot 

Leg 

Thigh 

Shoulder 

3 

4 

4 

5 

Forearm 

4 

4 

6 

5 

Hand 

I 

2 

3 

3 

Fingers 

0 

0 

2 

2 

Spatial  character  of  the  overlappings.  Thus,  for  example,  the 
total  number  of  possible  overlappings  is  nine  in  each  case,  and 
we  find  that  in  no  case  do  we  get  an  overlapping  of  the  toe  area 
onto  the  finger  area,  that  in  general  the  segments  close  to  the 
trunk  show  the  greatest  number  of  overlappings,  both  with  re- 
spect to  one  another  and  also  with  respect  to  the  more  peripheral 
segments.  This  would  indicate  a  possible  closer  relation  of  the 
thigh  movements  and  the  movements  of  the  hand  and  fingers, 
and  a  possible  closer  relation  of  movements  of  the  shoulder  with 
movements  of  the  foot  and  toes.  Until  the  movements  are  ana- 
lyzed to  a  greater  degree  than  is  done  at  this  time  this  can  be 
taken  only  as  a  suggestion. 

Leg  movements  within  the  arm  areas. — The  number  of  anomal- 
ous movements  of  this  character  is  less  than  that  of  the  arm 
movements  in  the  leg  areas.  In  2L,  on  the  outer  border  of  the 
arm  area,  there  is  a  small  area  the  stimulation  of  which  produced 
movements  of  the  thigh  and  of  the  leg,  and  at  the  frontal  edge 
of  this  area  the  stimulation  was  followed  by  knee  flexions  inde- 
pendent of  any  movement  of  the  parts  of  the  arm  segment.  At 
the  lower  portion  of  the  arm  area,  far  removed  from  the  main 
mass  of  the  leg  area,  two  small  areas  were  discovered  which  gave 
movements  of  the  thigh  and  leg  as  well  as  movements  of  the  arm 
segments,  in  one  case  the  leg  movements  being  combined  with 
movements  of  the  hand  and  fingers  and  in  another  case  with  move- 
ments of  the  forearm.  In  4R  thigh  and  leg  movements  were 
found  to  accompany  stimulation  of  the  area  in  the  central  portion 
of  the  large  arm  area  where  the  latter  bordered  upon  the  fissure  of 
Rolando. 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      137 

Only  two  hemispheres,  therefore,  showed  the  ipresence  of 
leg  movements  within  the  arm  areas  while  five  hemispheres  of  the 
total  of  nine  showed  arm  movements  within  the  leg  areas.  Al- 
though it  is  not  possible  at  this  time  to  determine  the  import  of 
these  variations  it  appears  probable  that  they  indicate  a  greater 
degree  of  ease  of  liberation  of  the  arm  movement  impulse  or  a 
greater  degree  of  complexity  of  arm  connections.  Allied  to  the 
results  which  have  been  considered  in  the  preceding  paragraph 
similar  results  were  obtained  which  indicate  the  complexity  of 
these  movements  and  of  the  movement  control.  In  3R  head 
movements  in  combination  with  movements  of  the  shoulder  were 
obtained  by  the  stimulation  of  the  cortex  at  the  uppermost  part  of 
the  arm  area  although  the  characteristic  area  for  head  movements 
lies  lower  in  the  field,  approximately  below  that  for  the  arm  seg- 
ments. In  the  same  hemisphere  head  movements  were  found  to 
follow  the  stimulation  of  the  area  close  to  the  bifurcation  of  the 
subsidiary  fissure  which  is  shown  in  the  diagram.  This  is  far 
removed  from  the  principal  head  area.  At  the  same  time  men- 
tion may  be  made  of  the  fact  that  in  4R  the  stimulation  of  the 
area  which  is  shown  as  a  blank  space  bordering  upon  the  fissure 
of  Rolando,  and  which  is  surrounded  by  arm  areas,  also  gave 
movements  of  the  tail  whereas  in  the  other  animals  in  which 
movements  of  this  organ  occurred  they  followed  stimulations  of 
the  areas  bordering  upon  or  near  the  longitudinal  sulcus. 

Relatively  non-stimulable  zones. — In  the  diagrams  of  Figure  2 
there  are  to  be  found  blank  spaces  within  the  cross-lined  areas,  or 
separating  the  cross-lined  areas.  This  indicates  that  these  areas 
are  unlike  the  surrounding  areas  in  that  they  are  non-stimulable 
or  relatively  non-stimulable.  This  was  mentioned  in  a  previous 
section  (p.  84),  where  it  was  also  said  that  when  an  apparent 
non-stimulable  area  was  found  the  strength  of  the  stimulating 
current  was  increased  to  see  if  the  area  was  really  non-stimulable. 
At  times  it  was  found  that  we  were  dealing  with  an  area 
with  heightened  threshold  because  the  increased  stimulus 
produced  characteristic  responses  similar  to  those  of  the  sur- 
rounding regions,  but  at  other  times  the  increased  stimulus 
did    not    produce    any    response.      Whenever    the    latter    was 


138  SHEPHERD  IVORY  FRANZ 

found  it  was  concluded  that  we  were  dealing  with  a  silent 
or  a  relatively  silent  area  on  account  of  the  fact  that  any 
further  increase  of  current  strength  can  be  objected  to  on  the 
ground  that  the  spreading  of  the  current  is  more  likely  to  take 
place  and  to  stimulate  not  only  at  the  spot  at  which  the  electrodes 
are  placed  but  also  adjacent  collections  of  cells.  Some  objection 
may  be  raised  against  the  universal  application  of  this  method 
of  determining  the  silent  character  of  the  areas,  and  I  do  not 
press  the  point  at  the  present  time  although  the  conclusion  appears 
to  me  to  harmonize  with  a  number  of  other  facts  which  have 
previously  been  reported  by  others.  Whatever  explanation  we 
may  select  for  the  findings,  whether  we  consider  them  to  be  indica- 
tive of  a  non-stimulable  character  of  the  special  regions  or  of  a 
relative  lowering  of  irritabiHty,  it  is  of  special  interest  to  note 
that  similar  phenomena  were  not  observed  in  the  results  of  the 
series  of  stimuli  to  all  the  hemispheres  which  were  tested.  At  the 
same  time  in  a  comparison  of  the  hemispheres  for  which  this 
phenomenon  was  noted  there  is  found  great  variation.  Thus  we 
note  the  leg  area  in  iR  to  be  divided  into  smaller  areas,  which 
division  is  probably  of  the  character  described  above  although 
not  obviously  so.  The  amount  of  space  covered  by  this  dividing 
area  is  great  in  the  case  of  2R,  and  the  relatively  non-stimulable 
zone  in  this  hemisphere  almost  divides  the  arm  area  into  two 
separate  areas.  Fewer  of  these  non-stimulable  areas  were  found 
in  the  leg  areas  than  in  the  arm  areas,  which  may  be  an  indication 
of  a  greater  fixity  or  of  a  higher  degree  of  exactness  in  the 
development  for  the  former.  In  this  connection  the  diagrams 
of  the  other  figures  are  of  interest  since  they  show  similar  phe- 
nomena associated  with  the  areas  for  the  individual  segments. 
It  will  be  observed  that  in  most  of  the  diagrams  of  the  arm  areas 
(shoulder,  forearm,  etc.)  these  divisions  occur  and  that  they  are 
less  frequent  in  the  leg  areas.  It  may  be  expected  that  the  divi- 
sions would  be  more  evident  in  the  arm  segment  areas  on  account 
of  the  multiplication  of  the  blank  areas  in  each  of  the  diagrams, 
but  a  careful  comparison  of  all  the  diagrams  referring  to  the 
arm  areas  shows  that  the  divisions  are  more  numerous  than  those 
of  the  leg  areas  even  when  the  non-stimulable  zones  that  are 
common  to  all  are  omitted. 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      139 

Summary :  In  the  hemispheres  which  were  investigated  there 
was  found  a  number  of  points,  or  areas,  the  stimulation  of  which 
gave  movements  unhke  those  of  the  surrounding  regions.  This 
was  especially  marked  in  some  of  the  hemispheres  while  others 
showed  none  of  this  crossing  or  combination  of  control.  The 
number  of  cases  in  which  arm  movements  were  found  to  be  asso- 
ciated with  the  stimulation  of  leg  areas,  or  arm  movements  asso- 
ciated with  leg  movements  when  the  surrounding  areas  gave  only 
leg  movements,  is  greater  than  that  of  arm  movements  from  the 
stimulation  of  leg  areas.  A  number  of  non-stimulable  or  rela- 
tively non-stimulable  zones  were  found  surrounded  by  normally 
stimulable  areas. 


GENERAL  DISCUSSION  (THEORETICAL) 

The  results  of  these  experiments  lead  to  certain  conclusions 
which  have  widespread  application  regarding  the  functions,  or 
functional  connections,  of  all  portions  of  the  cerebrum.  It  is 
apparent  that  in  this  area,  which  has  very  generally  been  con- 
sidered to  have  neural  connections  directly  (or  indirectly  through 
intervening  neurones)  with  the  efferent  cellular  elements  in  the 
spinal  cord,  there  is  not  the  definiteness  of  localization,  and  there- 
fore of  connection,  which  has  been  supfKDsed.  The  fact  that  there 
is  a  variation  in  the  extent  of  the  leg  or  the  arm  area  in  different 
animals  indicates  that  motor  cells  located  in  similar  locations  may 
send  impulses  in  different  directions.  The  fact  that  the  stimula- 
tion of  certain  spatially  located  points  in  an  area  which  usually 
gives  rise  to  movements  of  the  thigh  may,  for  example,  result  in 
combined  movements  of  the  arm  as  well  as  of  the  thigh  is  also  an 
indication  of  a  complex  mechanism.  This  becomes  more  evident 
when  we  realize  that  such  combined  movements  are  obtainable 
upon  stimulation  of  the  cortex  of  one  animal  and  not  when  the 
cortex  of  another  is  stimulated  (or  if  obtained  in  the  second 
animal  the  combined  movement  differs  in  quality).  Furthermore, 
although  the  data  in  regard  to  the  differences  of  control  from  the 
two  hemispheres  of  the  same  animal  are  not  as  complete  as  they 
might  be,  the  facts  from  the  four  monkeys  of  which  both  hemis- 
pheres were  investigated  indicate  that  there  is  a  considerable 
difference  in  the  connections  which  are  established  from  each 
hemisphere.  All  the  varying  results  are,  however,  of  interest  in 
that  they  lead  to  rather  definite  theoretical  conclusions  and  in 
that  they  lead  to  a  better  understanding  of  the  variability  in  con- 
trol which  are  evidenced  by  the  normal  behavior  of  different 
animals  and  by  that  of  different  individuals  and  of  different 
races  of  man. 

In  connection  with  the  results  of  the  present  series  of  tests,  the 
results  of  the  recent  experiments  of  Brown  and  Sherrington  (3) 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      141 

on  the  reversibility  of  action  of  allied  centers^  in  the  cortex  are  of 
very  great  importance.  These  investigators  found  that  in  the 
monkey's  cerebral  cortex  there  were  several  centers,  or  groups  of 
cells,  the  stimulation  of  which  normally  brought  about  flexion,  and 
other  adjacent  groups  or  centers  which,  stimulation  showed,  were 
normally  concerned  in  the  production  of  extension  movements. 
The  stimulation  of  one  of  the  flexion  centers,  it  was  furthermore 
found,  would  bring  about  a  slight  or  medium  degree  of  flexion, 
while  that  of  another  would  produce  an  extreme  degree  of  flexion. 
Similar  results  were  obtained  upon  stimulation  of  the  extension 
centers,  or  groups  of  cells.  When,  however,  a  flexion  center 
was  stimulated  repeatedly  it  was  discovered  that  the  flexion  re- 
action did  not  remain  of  the  same  intensity  as  that  which  was 
originally  found.  There  were  changes  in  the  degree  of  the  mus- 
cular contractions  in  a  series  of  stimulations  of  the  same  cerebral 
spot  and  in  certain  cases  flexion  eventually  was  replaced  by  the 
opposed  movement  of  extension.  From  the  results  of  this  exper-  >, 
iment  we  see  that  the  repeated  stimulation  of  one  area  may  result 
in  a  reversal  of  the  function,  such  a  reversal,  however,  being 
probably  only  an  exaggeration  due  to  the  normal  connections  and 
perhaps  only  a  magnification  in  certain  respects  of  the  normal 
functions  of  such  a  center.  After  pointing  out  this  fact  the  aur 
thors  conclude  (page  277)  that  "the  frequence  of  reversal  as  a 
phenomenon  attaching  to  the  reactions  of  points  in  the  motor 
cortex  suggests  that  one  of  the  functions  of  the  cortex  may  be 
the  performance  of  reversals,  and  that  the  greater  predominance 
of  reversal  under  cortical  than  in  purely  spinal  or  decerebrate 
reflexes  is  because  reversal  is  one  of  the  specific  offices  of  the 
cortex  cerebri." 

In  the  same  series  of  experiments  Brown  and  Sherrington  also 
noted  another  result  which  is  of  great  interest,  namely  the  varia- 
tion in  the  degree  of  activity  accompanying  the  stimulation  of  the 
different  centers  at  different  times.  When  on  the  cortex  of  an  ani- 

^  The  term  center  in  the  discussion  implies  no  metaphysical  assumption. 
It  is  a  convenient  and  short  designation  for  "a  collection  of  cells  the  stimu- 
lation of  which  may  result  in  certain  reactions  and  the  extirpation  of  which 
may  bring  about  certain  deficiencies  of  activities  or  behavior." 


142  SHEPHERD  IVORY  FRANZ 

mal  the  center  for  extreme  flexion  was  definitely  located  {i.e., 
spatially  in  relation  to  the  other  flexion  centers)  and  the  animal 
was  permitted  to  recover  for  some  hours  before  a  second  experi- 
mental determination  of  this  center  was  made,  it  was  discovered 
that  the  second  determination  of  the  point  for  extreme  flexion 
did  not  always  correspond  with  the  point  originally  determined. 
—In  other  words,  repeated  stimulation  of  the  same  center,  or  group 
of  cells,  did  not  always  result  in  the  production  of  the  same 
quantity  or  grade  of  movement.  Thus,  the  center  which  on  the 
first  stimulation  gave  the  greatest  amount  of  reaction  might  be 
found  to  give  a  less  amount  of  reaction  at  another  time  and  the 
area  which  gave  the  small  amount  of  flexion  or  extension  at  the 
time  of  the  original  or  first  experiment  was  sometimes  found  to 
give  a  greater  amount  of  flexion  or  of  extension  in  a  second  test. 

A  phenomenon  or  reversal  of  another  character  was  also  found. 
When  the  stimulation  of  a  center  resulted  in  a  continued  or  epi- 
leptiform contraction  a  second  stimulation  of  the  same  center 
might  cause  an  inhibition  of  this  movement.  In  the  same  series 
of  experiments  it  was  found  that  "in  one  case  the  same  point 
which  yielded  primary  extension  with  much  regularity,  on  re- 
examination twenty-eight  hours  later  in  the  same  animal,  yielded 
at  first  primary  flexion  instead  of  the  primary  extension" 
(page  252). 

Closely  allied  to  the  results  of  the  present  work  is  the  fact, 
which  Brown  and  Sherrington  note,  that  "in  some  experiments, 
the  area  whence  extension  points  could  be  chosen  has  been 
distinctly  larger  than  in  others"  (page  252).  These  authors  con- 
k  elude  that  "this  variability  signifies  less  a  difference  in  the  per- 
manent arrangement  than  a  diifiference  in  the  condition  of  the 
nervous  system  from  time  to  time,"  but  this  conclusion  does  not 
appear  to  be  in  line  with  the  facts  which  have  been  recorded  here, 
nor  does  it  appear  to  me  adequate  to  explain  all  of  the  facts  which 
these  authors  have  recorded. 

Most  of  the  recent  work  on  the  recovery  of  voluntary  control 

^    following  various  forms  of  nerve  anastomosis  also  shows  that 

"^there  is  not  the  degree  of  definiteness  of  control  from  a  particular 

portion  of  the  cerebral  cortex  which  has  been  assumed.    Were  a 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      143 

particular  cell  endowed  with  the  particular  function  of  sending 
impulses^  to  bring  about  only  one  special  movement  of  the  arm, 
it  could  never  be  used  to  bring  above  a  movement  of  the  face. 
Were  the  activities  of  such  a  cell  associated  with  or,  as  some 
clinicians  hold,  due  to  "memory  images"  of  shoulder  movements, 
for  example,  there  would  probably  never  be  the  possibility  of  mov- 
ing the  face  except  by  thinking  of  it  as  the  shoulder.  In  man,  as^ 
far  as  our  knowledge  goes,  the  acquired  ability  to  move  the  face 
when  there  has  been  an  anastomosis  between  the  peripheral  por- 
tion of  the  facial  nerve  and  the  central  end  of  the  accessory  nerve 
is  not  associated  with  any  "memory  images"  or  thinking  about  the 
shoulder.  This  conclusion  is  also  forced  upon  us  because  of  the 
recovery  of  the  facial  mimetic  movements,  which  are  reflex  in 
character. 

The  experimental  work  on  animals  gives  us  many  facts  of  value 
in  this  connection.  Kennedy  (8),  it  will  be  remembered,  crossed 
the  nerves  for  the  flexor  and  the  extensor  movements  of  the  dog's 
leg  and  noted  that  after  a  time  the  animal  was  able  to  move  the 
leg  quite  properly.  He  also  found  that  when  the  motor  areas  of 
the  cerebrum  were  stimulated,  the  stimulation  of  the  portion  of  the 
cortex  which  is  considered  to  be  a  flexion  "center"  was  accom- 
panied by  an  extension,  and  vice  versa,  indicating  that  new  brain 
conections  had  been  formed  because  of  the  peripheral  anastomosis. 
The  observation  that  the  animal  recovered  to  a  very  great  extent 
the  normal  power  of  the  use  of  the  leg  in  locomotion  demonstrates 
that  there  has  been  a  rearrangement  in  anatomical  distribution  of 
the  individual  neurones.  The  results  of  the  cerebral  stimulation 
experiments  on  the  brain  of  this  dog  are,  however,  not  conclusive 
evidences  of  the  rearrangement  of  function  in  the  neighboring 
cerebral  areas  because  the  flexor  and  the  extensor  centers  are 
anatomically  very  intimately  related.  The  recent  work  of  Brown 
and  Sherrington,  which  has  already  been  described,  has  well 
demonstrated  that  there  may  be  a  reversal  of  function  of  these 
areas,  and  it  is  theoretically,  and  practically,  possible  that  the  re- 

*The  use  of  the  term  impulse  in  this  connection  is  convenient,  although  it 
is  recognized  that  some  physiologists  object  seriously  to  its  use,  because  it 
appears  to  imply  something  more  than  physico-chemical  changes. 


144  ^       SHEPHERD  IVORY  FRANZ 

suits  of  the  cerebral  stimulation  experiments  of  Kennedy  were 
due  to  the  normal  physiological  relationships  of  the  flexion  and 
the  extension  centers. 

When,  however,  we  deal  with  the  altered  innervations  of  parts 
which  are  not  as  closely  associated  physiologically  the  same  prob- 
abihties  do  not  exist.  The  further  experiments  of  Kennedy  (7) 
are,  therefore,  less  open  to  question,  for  he  found  it  was  possible 
to  obtain  the  return  of  function  in  the  appropriate  parts  when  he 
connected  the  central  portion  of  the  cut  spinal  accessory  or  the 
central  portion  of  the  cut  hypoglossal  with  the  distal  portion  of 
the  cut  facial  nerve.  After  these  operations  it  was  found  that  the 
first  movements  in  the  area  innervated  normally  by  the  facial 
nerve  came  in  58  and  32  days  respectively,  and  in  about  100  days 
there  was  found  to  be  a  recovery  of  the  voluntary  control  of  the 
closure  of  the  eye  and  of  other  parts. 

Other  motor  areas  of  the  cerebral  cortex  which  are  spatially  less 
closely  allied  are  also  found  to  have  the  ability  to  assume  func- 
tions not  originally  pertaining  to  them.  Thus  Osborne  (9)  and 
Kilvington,  in  their  very  suggestive  research,  found  that  if  one 
brachial  plexus  was  served  and  Some  strands  were  carried  over 
from  the  opposite  plexus  and  united  with  the  distal  parts  of  the 
one  which  had  been  severed  regeneration  of  the  nerve  took  place. 
This  nerve  regeneration  was  accompanied  by  a  complete,  or  almost 
complete,  return  of  function  in  both  forelimbs.  It  was  further- 
more determined  that  if  the  cerebral  cortex  in  the  forelimb  area 
was  stimulated  on  the  side  contralateral  to  the  completely  cut 
nerve  (which  normally  innervates  the  limb  supplied  by  the  nerves 
of  the  brachial  plexus  which  had  been  cut),  no  reaction  resulted, 
but  if  the  cortex  of  the  homolateral  hemisphere  was  stimulated, 
movements  of  both  forelimbs  were  produced.  This  is  a  clear  and 
convincing  demonstration  of  the  fact  that  the  function  of  a  par- 
ticular area  depends  more  upon  the  connections  that  are  made 
than  upon  any  hypothetical  inherent  or  innate  function,  and  fur- 
ther, that  the  functions  of  a  particular  area  may  materially  change 
in  accordance  with  the  paths  which  are  formed.  The  recovery 
of  normal  function  also  indicates  that  the  impulses  received  from 
the  receptive  areas  of  the  cerebrum,  which  are  considered  to  be 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      14S 

necessary  for-  the  proper  performance  of  voluntary  movements, 
are  not  singularly  direct.  Such  impulses,  following  the  assump- 
tion of  their  necessity  and  importance,  must  in  an  intact  animal 
go  in  certain  directions  and  in  the  operated  animal  in  other  direc- 
tions by  other  paths. 

The  experimental  work  of  Boeke  (1)  is  also  of  suggestive  im- 
portance, showing  as  it  does  that  there  is  a  possibility  of  regenera- 
tion even  in  those  cases  in  which  the  cross-sutured  nerves  differ 
by  as  much  as  they  do  in  the  case  of  the  sensory  and  the  motor 
nerves.  In  some  cases  Boeke  found  that  if  the  central  end  of 
the  cut  hypoglossal  nerve  was  joined  to  the  distal  portion  of  the 
sectioned  lingual  n'erve  regeneration  of  the  fibers  took  place.  He 
has  also  been  able  to  demonstrate  that  under  these  conditions  some 
of  the  efferent  fibers  of  the  hypoglossal  actually  progressed  to  the 
surface  of  the  tongue  and  made  connections  with  taste  buds.^ 
It  is  not  definitely  proven  that  these  connections  resulted  in  a 
return  of  the  ability  to  taste  for  those  areas  of  the  tongue  which 
had  been  deprived  of  his  function  by  the  section  of  the  lingual 
nerv^  More  experiments  and  more  crucial  tests  i^especting  this 
matter  are  necessary  before  we  may  say  there  has  been  a  complete 
demonstration  of  the  functional  regeneration.  The  fact  remains, 
however,  that  the  possibility  of  anastomosis  between  a  sensory  and 
a  motor  nerve  has  been  demonstrated.  What  variations  in  sen- 
sory or  motor  activity  have  been  the  result  of  these  tests  will 
doubtless  later  be  determined.  That  the  normally  efferent  fibers 
may  regenerate  and  pass  to  the  sensory  end  organs  as  well  as  to 
muscle  cells  is  a  fact  weighted  with  suggestions  regarding  many 
practical,  but  especially  theoretical,  problems. 

Variations  in  the  motor  responses  to  cerebral  stimuli  have  also 
been  recorded  by  the  Vogts  (H),  not  only  in  different  animals 
of  the  same  species  but  also  in  different  species  of  animals.  It 
seems  to  me  probable  that  many  of  the  discussions  of  the 
physiologists  and  of  the  clinicians  of  the  past  in  which  there 

*At  the  present  stage  work  of  this  nature  has  more  definite  interest  in 
connection  with  the  peripheral  distribution  of  the  nerve  fibers.  It  can  readily 
be  understood,  however,  that  the  possible  central  (i.e.,  cerebral)  relations  are 
most  important.  Confirmations  of  Boeke's  work  are  urgently  needed,  espe- 
cially in  relation  to  the  variations  in  behavior  of  the  operated  animals. 


146  SHEPHERD  IVORY  FRANZ 

were  charges  and  counter-charges  of  ignorance,  or  of  misstate- 
ment, or  of  technical  defects  were  due  to  the  fact  that  these 
variations  were  not  known  or  were  not  recognized.  I  believe  that 
if  this  fact  had  been  known  and  understood  many  acrimonious 
discussions  would  have  been  prevented. 

The  Vogts  hold  to  the  view  that  the  variations  are  due  "in  part 
to  special  development  of  other  pallium  fields,  and  in  part  to  varia- 
itons  in  the  functional  capacity  of  performance."  They  further- 
more assert  that  nothing  prevents  the  "connecting  causally  all 
variations  in  the  number  of  foci  and  in  the  extension  and  to  a 
certain  degree  also  variations  in  the  excitability  of  a  certain  field 
of  stimulation  with  differences  in  the  specialization  of  its  motor 
functions." 

On  the  other  hand  Sherrington  (10)  has  written:  "Every  in- 
crease in  the  number  of  links  composing  the  nerve  cell  chain  seems 
to  increase  greatly  the  uncertainty  of  its  reaction  in  artificial  ex- 
citation. ...  A  cortex  cerebri  might  well  therefore  have  been 
expected  to  yield  under  artificial  excitation  only  extraordinarily 
inconstant  results.  To  Hitzig  and  Fritsch,  and  to  Ferrier,  we 
owe  the  pregnant  demonstration  that  as  regards  the  motor  region 
this  expectation  is  not  well  founded."  That  this  constancy  is  not 
a  veritable  one  is,  I  think,  fully  shown  by  the  researches  of  the 
Vogts  as  well  as  by  the  results  of  the  present  study.  There  is  not 
the  degfee  of  constancy  in  the  motor  response  which  the  earlier 
investigators,  as  for  example  those  which  are  cited  by  Sherrington, 
contended  there  is.  Moreover,  the  later  results  obtained  by  Sher- 
rington in  conjunction  with  Brown  which  have  been  discussed 
above  must  also  be  taken  into  account,  for  it  appears  to  me  they 
amply  demonstrate  the  opposite  of  that  which  Sherrington  wrote 
eight  years  ago,  and  prove  that  the  stimulation  of  the  same  cere- 
bral point  at  different  times  produces  varieties  of  action. 

Whether  or  not  the  variations  in  movement  associated  with 
cerebral  stimulation  are  to  be  correlated  with  normal  individual 
activities,  an  explanation  which  is  only  slightly  advanced  beyond 
that  of  the  Vogts,  is  a  question  for  the  solution  of  which  the 
closest  observations  and  correlations  of  the  normal  activities  and 
the  extents  and  the  variabilities  of  the  motor  cerebral  control 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      147 

of  individual  animals  must  be  accumulated.  At  present  such  a 
view  appears  to  be  in  harmony  with  all  the  facts  which  are  known 
to  me  and  is  tentatively  put  forth  pending  further  studies.  It 
may  also  be  remarked  that  this  view,  in  a  special  form,  has  been 
suggested  by  Bolton  (2)  in  relation  to  his  anatomical  studies  of 
cases  of  "amentia"  and  of  "dementia,"  for  he  writes  that  the 
anatomical  variations  indicate  "the  likelihood  of  a  structural 
origin  for  individual  differences  in  mental  endowment,"^^  and 
on  the  other  hand  he  says  the  histologically  differentiated  areas 
indicate  the  "limits  of  educability." 

The  results  of  the  present  research,  in  conjunction  with  the 
data  of  others  which  have  been  recorded  above,  indicate  that  the 
connections  which  are  made  by  way  of  the  cortical  motor  cells 
are  not  definite  in  the  sense,  for  example,  that  there  is  a  passage 
of  an  impulse  from  a  Betz  cell  in  the  anatomically  defined  cere- 
bral motor  region  to  another  particular  efferent  cell  in  the  spinal 
cord,  but  that  the  connection  is,  in  special  senses  of  the  terms, 
promiscuous  or  irregular.  By  these  last  terms  I  mean  only  that 
the  connections  which  one  particular  efferent  or  afferant  cell 
makes  are  connections  with  a  great  number  of  neurones,  and  that 
the  impulses  resulting  from  the  activity  of  a  cell  body  may  affect 
many  other  cells.  Or,  in  other  terms,  an  impulse  arising  in  one 
cell  may  activate  or  influence  only  one,  or  any  number,  of  the 
cells  which  are  anatomically  associated  with  the  particular  cell 
with  which  we  deal.  It  is  quite  generally  admitted  that  a  cer- 
tain cell  has  the  possibility  of  sending  its  impulses  along  the  main 
neuraxon  and  this  is  the  view  which  is  implicitly  apparent  in 
most  discussions  of  cerebral  function.  But  it  is  also  obvious 
that  since  this  neuraxon  gives  off,  as  it  passes  to  its  final  goal, 
certain  collaterals  it  is  quite  as  reasonable  and  quite  as  logical  to 
conclude  that  it  has  also  the  possibility  of  sending  impulses  along 
any  one  of  these,  or  along  the  main  neuraxon  and  any  number 

"  This  is  not  quoted  as  an  indication  of  sympathy  with  the  methods  and 
other  conclusions  of  Bolton,  who  has,  in  fact,  introduced  forms  of  expression 
in  regard  to  cerebral-mental  relations  which  are  obviously  grossly  inaccurate. 
Thus,  to  be  specific,  he  says  that  by  means  of  language  "it  is  possible  to  per- 
form the  highly  intricate  processes  of  cerebral  association,"  and  that  "if 
words  spontaneously  arise  in  a  cerebral  center,"  whatever  these  things  mean. 


148 


SHEPHERD  IVORY  FRANZ 


of  the  collaterals,  or  along  one  or  more  of  the  collaterals  to 
the  exclusion  of  the  main  trunk.  It  is  this  later  method  of 
looking  at  the  activities  of  the  cerebral  cells  which  appears  to  me 
to  solve  some  of  the  great  difficulties  of  the  exclusive  neuraxon 
activity  hypothesis. 

The  illustration  which  is  presented  here   (Figure  ii)   is  one 

♦A^  tV*  ^C 


Figure  ii.  Illustrating  the  conception  of  the  possibility  of  impulses  in  one 
cell  influencing  different  cells,  thus  resulting  in  different  reactions  or  differ- 
ent behavior.  The  primary  cells  A,  B,  and  C,  may  be  equally  well  considered 
to  be  afferent,  efferent,  or  associational.  Each  cell  may  also  be  considered 
as  a  simplification  of  a  group  of  cells. 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      149 

which  gives  a  diagrammatic  conception  of  this  view."  The 
activity  of  the  cell  B  in  its  discharge  may  be  represented  as 
passing  in  any  one  or  more  of  the  directions  taken  by  the 
branches  of  its  neuraxon.  Thus  the  activity  of  this  cell  may 
result  in  the  stimulation  of  tht  cell  U,  or  the  cell  T,  or  the  cell 
V.  In  turn  the  activities  of  these  cells  (T,  U,  V)  may  result  in 
the  stimulation  of  muscles.  On  the  other  hand  the  activity  of 
cell  A  may  through  its  collateral  acting  upon  cell  /  result  in  an 
activity  of  cell  T,  and  the  activity  of  cell  C  acting  through  its 
collateral  on  cell  N  may  also  bring  about  activity  in  cell  V.  Or, 
cell  C  acting  through  its  collateral  on  cell  G  may  activate  cell  B 
so  that  the  characteristic  B  activities  may  be  obtained.  In  turn 
the  activity  of  cell  B  may  influence  those  of  cells  A  and  C  almost 
directly,  thus  bringing  about  reactions  in  parts  which  are  nor- 
mally controlled  by  those  cells,  for  example  those  parts  connected 
with  cells  P  and  R,  and  those  with  cells  Y  and  Z.  When  it  is 
considered  that  cell  B  may  be  taken  as  a  representative  of  a  so- 
called  sensory  cell,  or  an  efferent  cell  which  is  normally  made 
active  when  it  received  the  effect  of  an  impulse  from  some 
other  cell  or  cells  in  other  portions  of  the  cerebrum,  for  example 
from  a  sensory  or  associational  center,  and  that  there  may  be  many 
of  these  which  exert  an  influence  upon  it,  it  will  be  realized  that 
the  behavior  resulting  from  the  activity  of  a  primary  receptive 
cell  may  greatly  vary  from  time  to  time. 

This  neurological  conception  may  be  applied  to  the  under- 
standing of  the  behavior  differences  of  individuals  and  also  of 
the  same  individual  from  time  to  time.  It  appears  probable 
that  the  variations  in  behavior  of  different  animals  and  of  the 
same  animal  at  different  times  to  the  same  form  of  stimulation 
are  dependent  upon  the  great  number  of  connections  and  upon  the 
variations  in  activity  which  the  connection  variations  make 
possible.  On  the  hypothesis  that  the  connection  between  cor- 
tical cells  is  definite,  in  the  sense  that  one  cell  acts  solely  or 

"  A  few  words  of  caution  may  be  said  regarding  the  diagram  and  its  ac- 
companying paragraph  of  text.  Neither  should  be  taken  too  literally,  neither 
should  be  considered  to  be  more  than  an  indication  of  a  possibility,  and 
neither  should  be  judged  without  the  preceding  and  the  following  context. 


150  SHEPHERD  IVORY  FRANZ 

principally  upon  one  other  cell,  we  shall  have  great  difficulty  in 
explaining  the  phenomena  in  man  or  in  animals  which  are 
grouped  under  the  general  heading  of  habit  formation.  To  show 
this,  let  us  briefly  consider  the  facts  regarding  the  formation 
of  habit  in  several  animals.  We  shall  then  realize  how  the  same 
stimulus  may  result  in  different  reactions  in  different  animals, 
and  how  in  one  animal  at  different  times  different  reactions  may 
result  from  the  same  stimulus.  Conversely  also  we  shall  get 
some  neurological  insight  into  the  possible  reason  for  similar 
reactions  in  different  animals  from  different  stimuli.  On  the 
assumption  of  definite  connections  and  definite  paths  of  dis- 
charge such  facts  are  neurologically  almost  unexplainable. 

Let  us  take  for  consideration  a  young  cat,  four  to  six  months 
old,  since  an  animal  of  this  kind  is  readily  "educable."  If  the 
animal  is  hungry  it  will  be  better,  since  the  formation  of  the 
habit  is  then  more  readily  obtained  if  the  habit  has  one  of  its 
elements  concerned  with  the  obtaining  of  food.  We  prepare 
for  our  exf>eriment  a  box  with  narrow  slats  in  the  front  and  a 
small  door  which  is  closed  with  a  bolt.  The  knob  of  the  bolt 
is  attached  to  a  cord  which  runs  along,  but  an  inch  under,  the 
top  of  the  box  and  which  the  animal  can  reach  either  with  its 
claws  or  by  arching  its  back,  or  by  biting  with  its  teeth.  When 
the  cord  is  pulled  downwards  or  pushed  upwards  or  moved  side- 
ways the  bolt  is  also  moved.  Any  one  of  these  actions  (there 
may  be  others  and  also  combinations  of  two  or  more  of  these 
actions)  will,  if  sufficiently  strong,  result  in  th'e  loosening  of 
the  bolt  which  keeps  the  door  closed,  and  when  the  door  is  thus 
opened  the  cat  is  enabled  to  escape  and  to  get  a  particle  of  food 
which  is  placed  outside. 

When  we  place  a  cat  in  an  enclosed  space  of  this  character 
there  is  a  very  decided  change  in  the  behavior  of  the  animal. 
It  usually  becomes  very  active.  This  activity  we  may  describe, 
in  terms  which  are  not  directly  scientific  in  th'eir  psychological 
aspect,  as  being  due  to  the  desire  on  the  cat's  part  to  escape 
from  the  uncomfortable  situation  of  being  in  an  enclosed  place 
of  such  small  compass,  and  perhaps  partly  to  the  desire  for  the 
food  which  in  some  experiments  it  may  see  outside.    The  actions 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      151 

of  the  particular  cat  under  these  conditions  are  about  the  same 
as  those  of  other  animals  of  the  same  species  which  are  placed 
in  such  a  situation.  The  animal  begins  to  scratch  at  the  front 
of  the  cage,  at  the  door,  at  the  sides,  at  the  top.  It  turns  here 
and  there,  it  takes  hold  of  everything  or  anything  which  it  can 
reach.  These  movements  are  not  performed  in  any  apparently 
logical  order  or  in  any  apparently  intelligent  manner  since  the 
animal  may  at  first  try  one  corner,  then  the  top,  perhaps  next 
the  door.  If  these  movements  do  not  result  in  the  escape 
of  the  animal  ifrom  the  "unpleasant"  situation  the  cat  may 
remain  quiet  for  a  time  and  begin  all  over  again  scratching  at 
a  front  corner  or  a  back  corner,  trying  the  top,  the  door,  the 
slats  at  the  front.  Even  though  the  special  movements  do  not 
result  in  the  release  which  is  sought  the  movements  are  con- 
tinued, and  if  the  cat  tries  one  thing  and  does  not  escape  by 
so  doing  it  may  return  to  the  first  which  it  had  previously  found 
unsuccessful.  The  random  movements,  if  they  are  continued 
for  a  sufficiently  length  of  time,  eventually  result  in  the  animal's 
moving,  either  by  clawing  or  by  arching  its  back  or  by  biting, 
the  cord  which  holds  the  bolt.  When  the  bolt  has  thus  been 
lifted  the  activities  of  the  animal  may  be  continued  for  some 
seconds  or  minutes  before  it  realizes  or  recognizes  that  the 
door  is  open  and  there  is  a  possibility  of  escape.  When  the 
animal  escaj>es  from  the  situation  it  finds  the  food  or  it  is  given 
a  small  piece  of  food.  When  it  is  returned  to  the  box  which  is 
again  bolted  it  goes  through  the  same  kinds  of  activities,  claw- 
ing here,  biting  there,  resting,  performing  movements  which  are 
apparently  purposeless  since  they  are  not  directed  to  the  part  of 
the  box  by  which  escape  becomes  possible,  or  towards  the 
mechanism  whereby  the  door  can  be  opened.  In  its  random 
movements  it  again  scratches  the  cord,  and  again  escapes  and 
gets  food.  At  the  next  trial  the  animal  goes  through  the  same 
sort  of  movements.  Finally  it  claws  the  cord,  gets  out,  and  in 
succeeding  tests  it  is  found  that  this  animal  which  at  first  escaped 
because  of  biting  the  cord  and  then  later  by  arching  its  back 
against  it,  and  again  by  clawing  at  the  cord  eventually  acquires 
the  habit  of  escape  by  utilizing  only  one  of  these  types  of  move- 


152  SHEPHERD  IVORY  FRANZ 

ment,  namely  the  scratching  or  clawing  at  the  cord.  Further- 
more it  is  found  that  when  an  animal  is  placed  in  this  situation 
it  eventually  acquires  the  habit  to  such  a  degree,  or  the  reaction 
is  facilitated  to  such  an  extent,  that  immediately  the  animal  is 
dropped  into  the  box  it  goes  to  the  particular  location,  claws  at 
the  cord  thus  opening  the  door,  escapes  and  obtains  the  food. 

Another  animal  goes  through  the  same  general  kinds  of  activi- 
ties in  its  escape  or  its  attempts  at  escape,  but  instead  of  acquir- 
ing the  habit  of  escaping  by  means  of  clawing  at  or  by  pulling 
the  cord,  it  acquires  the  habit  of  arching  its  back  and  rubbing 
against  the  cord,  thus  putting  the  cord  on  a  stretch  and  raising 
the  bolt.  A  third  animal  learns  to  escape  from  the  box  by  biting 
and  pulling  upon  the  cord. 

It  will  be  observed  that  as  far  as  we  can  detennine  all  three 
animals  have  been  stimulated  by  exactly  the  same  primary  forms 
of  stimuli.  They  have  been  stimulated  by  the  sight  of  the  box, 
by  the  appearance  of  the  slats  in  the  front,  by  the  closed  door, 
by  other  ill-defined  sensations  which  are  obtained  from  the  con- 
finement, perhaps  from  the  stimulation  of  a  variety  of  organs 
which  go  to  make  up,  in  human  perceptual  terms,  the  general 
feeling  of  being  enclosed  in  the  box.  The  sensory  elements 
which  are  present  in  these  three  cases  we  most  likely  have  the 
right  to  conclude  are  the  same.  The  emotional  elements  or  con- 
comitants we  do  not  know,  if  any  exist,  and  we  have  at  present 
no  means  of  determining  the  similarity  or  variety  of  these  mental 
conditions  if  they  exist.  It  is  to  be  noted  however  that  although 
the  sensory  stimuli  are  the  same  the  behavior  to  which  the  stimuli 
lead  differs  in  the  three  animals.  The  reactions,  it  will  be  ob- 
served, have  one  thing  in  common,  namely  that  they  result  in 
the  escape  of  the  animal.  The  actual  means,  however,  of  pro- 
ducing this  desired  situation  differs  for  the  three  animals. 
Neurologically  it  is  not  only  likely  but  it  is  almost  certain  that 
the  impulses  from  the  sense  areas,  those  so-called  associational 
impulses  which  start  from  the  cells  in  the  sensory  regions  of 
the  brain,  eventually  concentrate  in  these  three  animals  in  dif- 
ferent motor  areas,  or  to  put  the  matter  in  more  probable  terms, 
that  the  impulses  originating  in  similar  sensor}^  cells  in  all  three 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      153 

animals  reach  (a)  the  same  or  (b)  a  different  frontal  lobe  cell 
or  group  of  cells  in  all  animals,  and  that  (a)  this  similar  frontal 
cell  or  group  of  cells  discharges  into  different  cells  in  the  pre- 
central  area,  or  that  (b)  the  different  frontal  cells  influence 
motor  cells. 

Now  it  will  furthermore  be  found  that  if  an  animal  which 
has  acquired  the  habit  of  escape  from  a  box  of  this  character, 
either  by  clawing  or  biting  or  rubbing  against  the  cord,  be 
placed  in  the  same  box  and  the  movement  which  it  has  been 
accustomed  to  make  results  in  no  food  or  in  no  release, 
this  movement  is  gradually  given  up.  The  situation  becomes 
different,  although  the  sensory  stimuli  remain  the  same.  By 
holding  the  bolt  or  by  making  some  external  change  in  the 
mechanism  (which  is  not  seen  by  the  animal)  to  prevent  the 
escape  by  any  movement  of  the  cord,  but  to  permit  the  escape 
whenever  the  animal  sits  quietly  and  licks  itself,  or  washes  its 
face  by  the  characteristic  series  of  paw  movements,  or  scratches 
itself,  the  animal  soon  gives  up  the  first  habit  which  it  had 
formed  and  replaces  it  by  behavior  which  in  itself  has  not 
apparently  any  direct  bearing  upon  the  desired  result.  We  then 
have  a  similar  primary  series  of  stimuli  which  at  one  time 
results  in  a  particular  mode  of  activity  (clawing  the  cord), 
and  at  another  time  in  a  different  mode  of  activity  (licking 
itself)  in  the  same  animal.  Both  lead  to  what  may  be  con- 
sidered the  desired  result,  namely  the  escape  from  the  enclosed 
box. 

It  should  be  understood  that  the  sensory  stimuli  in  two  ex- 
periments of  this  character  are  not  the  same  in  their  totality. 
The  initial  or  primary  sensory  stimuli  are,  however,  the  same. 
When  after  the  receipt  of  the  primary  sensory  stimulation  a 
reaction  is  produced  the  reaction  results  in  an  additional  sensory 
stimulation,  and  this  secondary  stimulation,  or  the  combination 
of  the  secondary  with  the  primary,  may  give  rise  to  another 
reaction.  The  animal  which  claws  first  at  the  front  of  the 
cage  after  the  receipt  of  the  primary  stimulation  has  thereby 
a  character  or  combination  of  stimulation  different  from  that  of 
the  animal  which  first  reaches  for  the  top  of  the  cage  and  tries 


154  SHEPHERD  IVORY   FRANZ 

to  climb  out  in  that  way.  Each  animal  however  does  have 
the  same  primary  stimulation,  or  at  least  the  same  general 
primary  stimulation,  visual,  tactile,  organic,  etc.  To  go  back 
to  the  original  stimulation  we  may  even  vwonder  why  such 
similar  primary  stimuli  have  produced  such  diverse  methods  of 
behavior  as  that  of  clawing  at  the  slats  at  the  front  of  the 
cage  and  that  of  trying  to  bite  the  slats  at  the  top.  In  either 
case,  whether  we  consider  the  primary  stimulus  or  the  collec- 
tion of  stimulations  which  make  up  the  whole  experience  of 
the  animal  in  the  box  the  sensory  stimulations  are  sufficiently 
alike  to  presuppose  (on  the  basis  of  exactness  of  neurological 
connections)  an  approximate  similarity  in  the  activity  of  the 
cerebral  sensory  areas,  and  to  suggest  (on  the  same  hypothesis) 
that  the  efferent  cerebral  activity  should  be  the  same.  This  is, 
of  course,  on  the  very  generally  accepted  belief  that  the  impulses 
from  corresponding  sensory  cells  will  always  go  to  correspond- 
ing efferent  cells. 

On  thfe  hypothesis  that  there  are  definite  connections  estab- 
lished by  means  of  certain  cerebral  neurones,  and  the  hypothesis 
that  when  the  stimulation  reaches  a  particular  sensory  center 
it  flows  into  other  areas,  eventually  reaching  the  motor  area 
and  resulting  in  a  particular  type  of  movement,  the  varying 
activities  of  these  animals  are  not  understandable.  It  is  not 
an  explanation  to  say  that  one  animal  has  certain  sensory  stimuli 
like  those  of  another,  but  that  there  are  different  activities. 
•  Neurologically,  there  must  be  a  basis  for  the  different  kinds  of 
behavior.  When  we  consider  the  possibility  that  the  discharge 
from  a  certain  cell  may  pass  not  only  along  the  main  neuraxon 
but  also  along  any  one  or  all  of  the  collaterals  and  that  in  this 
manner  we  have  the  neural  activity  diffused,  we  have  a  possible 
explanation  of  the  variety  of  the  actions  of  the  same  animal 
under  similar  conditions.  If  the  receiving  cell  were  definitely 
and  solely  (anatomically  and  physiologically)  connected  with 
a  special  cell  or  group  of  cells,  the  same  sensory  stimulus  should 
result  in  the  same  kind  of  reaction  in  different  animals  and  in 
the  same  animal  at  different  times.  But  we  find  that  at  first 
the  cat  makes  many  random  movements.     In  other  words,  neu- 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      155 

rologicaJly  we  are  led  to  conceive  that  the  discharge  of  the 
sensory  or  receptive  element  is  not  only  along  the  main 
neuraxon  but  is  along  all  of  the  collaterals  as  Well,  and  each 
in  turn  acts  upon  its  cells  or  group  of  cells,  producing  impulses 
which  eventually  result  in  movements.  These  movements  are 
random,  i.e.,  not  directly  correlated  with  the  stimuli  nor  with 
the  desired  result,  but  as  the  experience  is  repeated  the  animal 
gives  up  all  but  a  certain  amount  of  the  reaction.  Its  behavior 
has  changed.  It  is  not  only  believable  but  probable  that  in 
the  development  of  a  particular  type  of  activity  or  in  the  pro- 
duction of  a  particular  association  or  habit,  such  as  that  of 
scratching  or  of  biting  or  of  arching  the  back,  we  may  have 
two  different  neurological  conditions.  To  use  the  simplified , 
diagram  which  has  been  given  above  we  may  say  that  at  first 
the  discharge  takes  place  along  all  the  branches  of  the  neuraxon, 
but  this  diffuse  discharge  eventually  gives  place  to  a  discharge 
along  one  of  the  collaterals  or  along  the  main  branch.  The 
variation  in  behavior  of  two  animals  may  then  be  due  to  the 
primary  stimulation  of  corresponding  cells,  but  in  otie  case  the 
habitual  reaction  is  determined  by  the  flow  of  the  impulses 
from  these  cells  along  the  course  of  the  main  neuraxon  and  in 
the  other  case  the  habitual  reaction  is  determined  by  the  passage 
olf  the  impulse  along  a  collateral  These  impulses  reaching 
different  efferent  elements  produce  the  varieties  of  behavior. 

The  results  of  the  preceding  study  (5)  of  the  variation  in 
symptoms  accompanying  similar  cerebral  lesions  in  the  insane 
have  also  a  bearing  upon  the  present  work.  In  that  study  it 
is  shown  that  in  four  collections  of  cases  of  pvatients  suffering 
from  different  mental  diseases,  in  whose  brains  atrophies  of 
the  frontal  or  anterior  regions  of  the  cerebrum  were  detected 
at  autopsy,  there  is  no  apparent  relation  between  the  symptoms 
and  the  localization  or  the  degree  of  fhe  cerebral  damage.  On 
the  assumption  that  there  are  definite,  in  the  sense  of  singular 
and  similar,  functions  and  functional  connections  in  each  hemi- 
sphere in  all  individuals  such  divergencies  in  the  symptomatology 
are  not  readily  understandable. 

At  the  same  time  the  accounts  of  my  experiments  on  the 


rs6  SHEPHERD  IVORY  FRANZ 

functions  of  the  frontal  lobes  (4)  contain  material  of  impor- 
tance for  the  understanding  of  the  cerebral  functional  relations. 
In  that  work  it  was  shown  that  after  an  animal  had  been  trained 
to  react  in  a  certain  way,  or  had  acquired  a  certain  habit,  the 
habit  was  lost  when  parts  of  the  frontal  lobes  were  separated 
from  the  remainder  of  the  brain  or  when  they  were  destroyed. 
Even  a:fter  the  loss  of  a  great  amount  of  the  frontal  regions 
such  an  animal  could,  however,  reacquire  the  lost  habit.  The 
reacquired  habit  could  again  be  destroyed  (or  lost)  if  addi- 
tional portions  of  the  frontal  lobes  were  extirpated,  and  in  some 
animals  it  was  possible  to  show  that  the  same  habit  could  be 
again  acquired. 

It  is  neither  satisfying  nor  sufficient  to  say  that  in  the  latter 
experiments  there  has  been  an  inhibition,  for  this  can  only 
give  to  the  facts  another  name.  Nor  does  it  suffice  to  say  that 
there  has  occurred  a  sort  of  "diaschisis,"  since  this  also  is  only 
another  means  of  expression  of  the  generalized  fact  of  loss 
of  function.  What  must  be  concluded  from  these  facts  is  that 
at  the  time  of  the  first  extirpation  there  was  a  "diaschisis,"  or 
blocking,  or  break,  in  the  normal  chain  of  cerebral  activity  (or 
neurologically  and  anatomically,  of  the  cerebral  connections). 
After  the  second  learning  of  a  habit  and  its  loss  subsequent 
to  a  second  and  more  extensive  extirpation,  "diaschisis"  may 
again  be  taken  as  the  explanation  of  the  fact.  Another  ex- 
planation beyond  those  of  "diaschisis"  or  inhibition  is  de- 
manded, however,  for  the  phenomena  of  learning  after  the 
first  extirpation  of  the  cerebral  area  through  or  by  which  learn- 
ing or  habit  formation  normally  is  possible.  It  is  obvious  that 
the  normal  {i.e.,  the  first)  paths  cannot  be  traversed  again, 
for  these  have  been  interrupted,  or  perhaps  abolished.  It  is 
obvious  that  new  paths  or  new  possibilities  of  connections  must 
be  available.  In  other  words  for  a  reasonable  explanation  we 
are  thrown  back  upon  the  assumption  that  the  paths  for  reac- 
tions are  not  the  simple  anatomical  unities  which  have  been 
commonly  believed  in  but  that  these  paths  are  diverse  and  that 
anatomically  as  well  as  physiologically  they  are  complex. 

If  the  neurological  path  for  the  formation  of  a  habit  is  a 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      I57 

fixity — from  a  certain  sensory  center  to  the  frontal  lobes  and 
thence  to  the  motor  cortex — a  break  at  any  portion  of  the 
path  (diaschisis,  if  you  will)  would  prevent  for  all  time  the 
reacquirement  of  thfe  lost  association.  That  there  is  no  such" 
fixity  is  evident  from  the  fact  that  releaming  is  possible.  The 
explanation  of  the  fact  must,  I  think,  be  sought  in  another 
dir^ection,  and  the  one  which  has  been  suggested  above  appears 
most  reasonable.  It  appears  probable  that  in  the  acquirement 
of  a  habit  certain  paths  are  traversed  and  that  they  have  a 
certain  fixity,  but  it  is  also  probably  true  that  these  paths  are 
not  the  only  ones  that  may  be  used  to  bring  about  the  desired 
connection  or  association  between  the  sensory  and  motor  end 
stations.  Most  probably  other  subsidiary  paths,  if  it  be  con- 
sidered necessary  or  advisable  to  differentiate  between  the  first 
path  and  other  paths,  or  relatively  subsidiary  tracts,  are  avail- 
able when  "diaschisis,"  or  inhibition,  or  other  similar  conditions 
supervene  to  prevent  the  normal  course  of  the  cerebral  impulses. 
The  conditions  of  variability  and  the  conditions  of  variation 
in  the  particular  responses  which  come  from  rather  definite 
sensory  stimulation  in  different  individuals  lead  us  to  a  better 
understanding  of  the  neurological  conditions  which  we  must 
believe  are  present  in  individual  cases.  It  is  not  sufficient  to 
say,  as  is  commonly  said,  that  past  experiences  determine  reac- 
tions, for  this  is  only  a  consideration  of  the  matter  from  the 
external  viewpoint.  It  gives  no  conception  of  the  neurological 
conditions  which  enter  into  the  matter.  At  present  I  think 
it  will  be  admitted  that  we  are  quite  ignorant  of  the  conditions 
which  result  in  the  selection  (not  necessarily  conscious  of 
course)  of  a  definite  path  in  the  nervous  system.  It  is  un- 
doubtedly true  that  certain  paths  are  fixed  in  the  sense  that 
one  neurone  has  fairly  direct  connections,  synaptic,  however, 
with  other  neurones  and  also  that  one  neurone  may  have  con- 
nections with  a  half-dozen  or  more  other  neurones.  Why  the 
stimulation  of  one  neurone  should  usually  give  rise  in  one  in- 
dividual to  a  particular  reaction  and  the  stimulation  of  what 
we  believe  to  be  a  corresponding  neurone  in  another  individual 
results  in  a  reaction  which  differs  somewhat  from  the  first,  we 


IS8  SHEPHERD   IVORY   FRANZ 

are  not  aware.  It  is,  however,  of  some  consequence  and  of 
some  importance  to  realize  that  there  are  greater  possibiHties  of 
connections  than  have  hitherto  been  assumed   or  beheved   in. 

^  Only  on  the  ground  of  the  assumption  of  variations  or  possi- 
bility of  variations  in  the  connections  or  in  the  patency  of 
collateral  and  main  tracts  may  we  understand  the  behavior 
phenomena  to  which  the  same  stimuli  give  rise  in  different  in- 

*dividuals.  Only  on  this  basis  can  we  understand  the  various 
activities  of  different  races  2Uid  of  different  individuals.  The 
different  races  have,  it  is  well  known,  different  types  of  reac- 
tion. Anatomically  we  have  no  good  reason  to  believe  that  the 
neuronic  connections  differ  widely  in  different  races,  nor  anato- 
mically have  we  any  good  reason  to  believe  that  the  neuronic 
connections  in  different  individuals  of  the  same  race  or  of  the 
same  family  differ  very  widely-  It  is  apparent,  however,  that 
physiologically  these  connections  are  very  greatly  different  for 
the  activity  of  the  neurones  gives  rise  to  behavior  of  quite 
different  characters. 

Thus  far  we  have  been  considering  what  is  doubtless  the 
most  simple  neurological  system,  a  system  much  simpler  by  far 
than  that  which  is  active  in  the  production  of  any  form  of 
behavior  higher  than  that  of  a  reflex.  When  we  deal  with  a 
system  containing  more  than  the  two  elements,  afferent  and 
efferent,  or  receptor  and  effector,  the  complexities  of  connec- 
tions and  the  possibilities  of  variation  in  the  physiological 
connections  become  apparent. 

**  In  this  respect  the  cerebral  cortex,  or  the  cerebrum  as  a 
whole,  may  be  looked  at  as  a  very  labile  organ  because  of  the 
numerous  possibilities  of  connections  which  may  be  made.  One 
cell,  let  us  say,  may  have  close  connections  with  a  half-dozen 
or  a  dozen  other  cells,  and  the  activity  of  the  primary  cell  need 
not  always  be  through  all  the  branches.  There  is  a  possibility 
of  a  change  in  the  direction  of  the  impulse  within  the  neurone. 
Thus  at  one  time  the  main  effect  may  be  due  to  the  influence 
exerted  through  a  certain  collateral,  and  at  another  time  the 
effect  may  be  due  to  the  impulse  passing  through  the  main 
axon  or  through  a  second  collateral.     If  this  be  true,  it  helps 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      I59 

to  understand  why  there  is  a  possibiHty  of  change  in  reaction 
and  a  variability  of  reaction  in  the  same  individual  from  time- 
to  time.  At  one  time  the  individual  may  have  a  discharge  from 
a  cortical  motor  cell  along  the  main  neuraxon  acting  upon  a 
definite  cell  located  in  a  definite  region  of  the  spinal  cord.  At 
another  time  the  dis<^harge  may  take  place  not  only  along  the 
main  neuraxon,  but  along  one  or  more  of  the  collateral  branches, 
the  actions  resulting  from  the  impulses  passing  through  the 
collaterals  being  added  to  that  due  to  the  impulse  along  the 
main  fiber,  and  the  actions  along  these  collaterals  producing 
effects  on  other  cells  which  either  inhibit  or  alter  in  character 
the  actions  which  were  formerly  produced,  or  new  reactions 
may  entirely  replace  the  original  activity  by  an  activity  of  a 
very  different  character. 

Nor  does  it  appear  necessary  to  believe  that  once  a  path, 
by  way  of  the  main  trunk  or  by  one  of  the  collaterals,  has  been 
fixed  that  this  fixity  is  a  permanency.  There  may  be  a  greater 
tendency  to  use  this  particular  path  after  it  has  been  used  a 
number  of  times,  but  it  may  be  said  with  certainty  that  the 
impulse  may  under  suitable  conditions  traverse  any  one  or  all 
of  the  other  collateral  paths.  In  a  state  of  "mental  panic"  a 
man  acts  very  differently  to  a  particular  stimulus  than  at  other 
times.  His  actions  may  be  more  diffuse  or  they  may  be  the 
opposite  of  those  which  he  habitually  performs  at  normal  times. 
Thus,  the  sounds  of  a  rifle-shot  heard  at  two  different  times 
although  both  be  of  equal  intensity  may  give  rise  to  varying 
reactions.  Especially  when  there  is  an  affective  condition,  such 
as  fear  or  apprehension,  do  we  find  such  changes  taking  place 
in  the  reaction. ^^  Neurologically,  however,  it  is  not  satisfying 
to  say  that  the  emotional  condition  gives  the  "set"  to  the  dis- 
charge of  a  particular  cell,  or  that  it  directs  the  character  of 
the  discharge,  for  we  know  nothing  of  the  neurological  con- 
ditions which  give  rise  to  or  accompany  affective  states.     But, 

"  Particularly  those  of  diffusion.  Neurologically  perhaps  we  may  con- 
sider such  diffusion  to  be  due  to  the  passage  of  impulses  from  a  cell  not 
only  along  the  path  commonly  traversed,  but  along  all  the  collateral  paths 
as  well. 


i6o  SHEPHERD  IVORY  FRANZ 

should  we  admit  that  the  emotional  state  can  alter  the  character 
of  the  motor  response  due  to  such  a  simple  stimulus  as  that 
of  the  sound  of  a  rifle-shot,  we  are  admitting  at  the  same  time 
that  the  impulse  from  a  sensory  cell,  or  group  of  cells,  may 
pass  through  certain  paths  at  one  time  and  through  other  paths 
at  other  times.  Such  a  condition  may  also  be  well  illustrated 
by  a  difference  in  behavior  when  no  affective  state  intervenes 
to  alter  the  reaction  or  when  the  affective  state  remains  the 
same  with  the  presentation  of  the  stimulus  at  different  times. 
An  illustration  of  this  is  that  of  the  differences  of  speech,  which 
are  special  reactions  or  forms  of  behavior,  when  the  same  picture 
of  an  object  is  shown  at  different  times.  At  one  time  such  a 
stimulus  (the  picture  of  an  apple)  may  bring  forth  the  reac- 
tion "Apple,"  at  another  time  "Apfel,"  and  at  a  third  time 
"Pomme." 

It  seems  most  likely  that  these  variations  in  activity  are  due 
to  physiological  variations  in  the  traversing  of  the  axon  or  the 
collaterals.  It  is  not  unlikely  that  as  conductors  the  axon  and 
the  collaterals  are  physiologically  equal,  that  they  may  be  utilized 
equally  well  or  equally  often  if  occasion  demands  it,  and  that 
the  definiteness  of  response  to  any  particular  stimulus  is  only 
a  relative  definiteness. 

In  considering  the  functions  of  the  cerebrum,  therefore,  we 
must  rid  ourselves  of  any  preconceived  notions  regarding  the 
fixity  or  definiteness  of  connections.  Fixity  or  definiteness  of 
an  anatomical  nature  there  undoubtedly  is,  but  this  iixity  or 
definiteness  is  on  the  physiological  side  a  multiplicity  of  fixities 
and  definitenesses.  One  cell  undoubtedly  communicates  with 
many  others,  and  while  this  is  an  anatomical  fixity  it  does  not 
result  in  a  physiological  definiteness  since  at  one  time  such  a 
cell  may  be  conceived  to  discharge  in  one  direction  along  one 
collateral  and  at  another  time  in  another  direction  along  another 
collateral.  At  present  we  may  not  have  sufficient  information 
to  guide  us  in  determining  the  reasons  for  the  discharge  in  this 
or  that  direction  but  the  facts  at  hand  indicate  that  discharges 
do  take  place  in  this  manner. 

Somewhat  similarly  we  must  explain  the  "facts  of  differences 


VARIATIONS  IN  DISTRIBUTION  OF  MOTOR  CENTERS      i6i 

in  symptoms  which  are  associated  with  similar  cerebral  lesions 
which  have  been  referred  to  in  a  preceding  paragraph.  If  we 
conclude  that  the  cerebral  paths  for  habits  (or  in  a  gross  phreno- 
logical sense,  for  mental  operations)  need  not  be  the  same  for 
all  individuals  such  symptomatological  dissimilarities  in  con- 
nection with  like  lesions  become  clearly  understandable.  If  all  in- 
dividuals do  not  use  the  same  limited  portions  for  the  same 
activities  (or  again  in  a  phrenological  vein,  for  the  same  mental 
processes)  the  destruction  of  similar  portions  of  the  cerebrum 
in  different  individuals  need  not  produce  the  same  symptoms. 
There  are  at  hand  sufficient  facts  in  clinical  neurological  litera- 
ture to  support  the  contention  that  similar  lesions  do  not  always 
produce  similar  clinical  symptoms  or  do  not  result  in  similar 
mental  alterations.  There  are  also  at  hand  sufficient  facts  to 
warrant  the  conclusion  that  dissimilar  lesions  may  produce 
similar  symptoms.  From  the  extreme  viewpoint  of  body-mind 
relations  (to  which,  however,  I  do  not  adhere)  such  facts  are 
sufficient  to  lead  to  the  conclusion  that  the  same  mental  opera- 
tions are  not  always  due  to  the  activities  of  the  same  parts 
of  the  brain.  From  a  more  conservative  standpoint  the  facts 
warrant  the  conclusion  that  the  same  forms  of  behavior  are 
not  always  due  to  the  activities  of  the  same  cerebral  cells.  That 
the  variability  in  the  functional  cerebral  connections  should  ever 
have  been  considered  doubtful  is  probably  due  to  the  phreno- 
logical views  which  have  influenced,  and  in  fact  pervaded,  all 
neurological  literature  for  many  years. 


REFERENCES 

1.  BoEKE,  J.    Die  Regenerationserscheinungen  bei  der  Vertei- 

lung   von   motorischen   und    rezeptorischen    Nervenfasem. 
Fflvger's  Arch.  f.  d.  ges.  Physiol.,  1913,  151,  57-64. 

2.  Bolton,  J.   S.     The  Brain  in  Health  and  Disease.     New 

York:  Longmans,  Green,  191 4.     Pp.  xiv  +  479. 

3.  Brown,  T.  G.  &  Sherrington,  C.  S.     On  the  Instability 

of  a  Motor  Point.  Proc.  Roy.  Soc,  1912,  B85,  250-277. 

4.  Franz,   S.   I.     On  the  Functions  of  the  Cerebrum:     The 

Frontal  Lobes.    New  York:  Science  Press.  1907.     Pp.  64. 
(Arch,  of  Psychol.  No.  2.) 
5  Franz,  S.  I.    On  the  Functions  of  the  Cerebrum:    Symptom- 
atological   Differences   Associated   with   Similar    Cerebral 
Lesions  in  the  Insane.    Pp.  1-79  of  this  Monograph. 

6.  Grunbaum,  a.  S.  &  Sherrington,  C.  S.     Observations  on 

the  Physiology  of  the  Cerebral   Cortex  of   Some  of  the 
Higher  Apes.    Proc.  Roy.  Soc,  1901,  B69,  206-209. 

7.  Kennedy,  R.     Experiments  on  the  Restoration  of  Paralyzed 

Muscles  by  Means  of  Nerve  Anastomosis.     Brit.  Med.  J., 
1911,2,14-15.     (Abst.) 

8.  Kennedy,  R.    Experiments  on  the  Restoration  of  Paralyzed 

Muscles  by  Means  of  Nerve  Anastomosis.    Proc.  Roy.  Soc, 
i9ii,B84,  75.78. 

9.  Osborne,  W.  A.  &  Kilvington,  B.     Central  Nervous  Re- 

sponse to  Peripheral  Nervous  Distortion.    Brain,  1910,  33, 
261-265. 

10.  Sherrington,  C.  S.    The  Integrative  Action  of  the  Nervous 
System.    New  York:  Scribner's,  1906.    Pp.  xvi  +  411. 

11.  Vogt,   C.   &  O.     Zur   Kenntnis   der  elektrisch   erregbaren 

Himrindengebiete.  /.  /.  Psychol,  u.  Neurol.,  1907,  8,  277- 
456- 


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